type: object required: - when - soap - text properties: icpc: description: |- *OPTIONAL* An ICPC1.1-NL code representing the nature of this journal note. Does not necessarily mean the patient suffers from the condition this ICPC represents. For example, a patient that comes in asking questions about signs of Diabetes would have journal text with ICPC `"T90.02"`, even if tests show they clearly do not have Diabetes Mellitus. Not all journal texts have a context, or a context that can be expressed as an ICPC. type: string pattern: '^[A-Z]\d{2}.\d{2}$' example: "A97.00" episode: description: |- *OPTIONAL* An ICPC1.1-NL code representing the problem / chronic illness that this journal note has been filed under. In our experience the difference between `icpc` and `episode` are not well demarkated and practicioners do not necessarily use these fields for their intended purpose. We suggest making no distinction between these 2 fields and accepting instead that this means journal text can have up to 2 ICPCs associated with them. type: string pattern: '^[A-Z]\d{2}\.\d{2}$' example: "T90.02" when: description: |- The date when this journal text was typed and registered. type: string format: date example: "2015-05-01" s: description: |- The journal text as typed by the practicioner for the 'S' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _S_ / _Subjectief_). A (transcription of the) description of the medical issue by the patient themselves. Can contain newlines, and can be quite long. For teleconsulting often contains everything the patient typed. type: string o: description: |- The journal text as typed by the practicioner for the 'O' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _O_ / _Objectief_). The description of the medical issue as observed by a trained medical practicioner. Can contain newlines, and can be quite long. For teleconsulting in particular, might be empty. type: string a: description: |- The journal text as typed by the practicioner for the 'A' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _E_ / _Evaluatie_). The diagnosis. Can contain newlines, and can be quite long. type: string p: description: |- The journal text as typed by the practicioner for the 'P' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _P_ / _Plan_). The course of action to take, or notes about next steps to deal with the issue raised in this journal entry. Can contain newlines, and can be quite long. type: string x: description: |- The journal text as typed by the practicioner for any non-SOAP field. Will be omitted if blank / not available. For source systems that do not work with the SOAP methodology, all journal text will be under this entry. Can contain newlines, and can be quite long. type: string practicioner: $ref: 'Practicioner.yaml' type: description: |- A code representing of the style of consult: * N - note, generally made without the presence of the patient, for example to register that some lab value was received by mail. * C - journal was registered as part of a consult (the patient was present). * V - journal was registered during a visit to the patient's location. * CT - journal was registered during a phone or other tele-consult. * Other codes exist; depends on source system. type: string example: C code: description: |- *OPTIONAL* If present, a short code representing a specific kind of action, such as a referral (`VER` - from dutch _Verwijzing_), `H` for medication recipe refill (dutch: _Herhaalrecept_), `REC` for prescribing a recipe, `LAB` for processing laboratory results, or `BVO` for a nationally organized checkup such as for Cervical Cancer (from dutch: _Bevolkingsonderzoek_). This coding depends on the source system, and not all source systems use this concept (if the source is such a system, this field is never present), nor do they use standardized codes for this concept. type: string example: REC