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95 lines
4.3 KiB
YAML
95 lines
4.3 KiB
YAML
type: object
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required:
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- when
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- soap
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- text
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properties:
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icpc:
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description: |-
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An ICPC1.1-NL code representing the nature of this journal note. Does not necessarily mean the patient suffers from the condition
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this ICPC represents. For example, a patient that comes in asking questions about signs of Diabetes would have journal text with ICPC `"T90.02"`,
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even if tests show they clearly do not have Diabetes Mellitus.
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Not all journal texts have a context, or a context that can be expressed as an ICPC.
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type: string
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pattern: '^[A-Z]\d{2}.\d{2}$'
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example: "A97.00"
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episode:
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description: |-
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An ICPC1.1-NL code representing the problem / chronic illness that this journal note has been filed under.
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In our experience the difference between `icpc` and `episode` are not well demarkated and practitioners do not necessarily use these fields
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for their intended purpose. We suggest making no distinction between these 2 fields and accepting instead that this means journal text
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can have up to 2 ICPCs associated with them.
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type: string
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pattern: '^[A-Z]\d{2}\.\d{2}$'
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example: "T90.02"
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when:
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description: |-
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The date when this journal text was typed and registered.
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type: string
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format: date
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example: "2015-05-01"
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s:
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description: |-
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The journal text as typed by the practitioner for the 'S' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _S_ / _Subjectief_).
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A (transcription of the) description of the medical issue by the patient themselves.
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Can contain newlines, and can be quite long. For teleconsulting often contains everything the patient typed.
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type: string
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o:
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description: |-
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The journal text as typed by the practitioner for the 'O' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _O_ / _Objectief_).
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The description of the medical issue as observed by a trained medical practitioner.
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Can contain newlines, and can be quite long. For teleconsulting in particular, might be empty.
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type: string
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a:
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description: |-
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The journal text as typed by the practitioner for the 'A' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _E_ / _Evaluatie_).
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The diagnosis.
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Can contain newlines, and can be quite long.
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type: string
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p:
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description: |-
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The journal text as typed by the practitioner for the 'P' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _P_ / _Plan_).
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The course of action to take, or notes about next steps to deal with the issue raised in this journal entry.
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Can contain newlines, and can be quite long.
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type: string
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x:
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description: |-
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The journal text as typed by the practitioner for any non-SOAP field.
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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.
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Can contain newlines, and can be quite long.
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type: string
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practitioner:
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$ref: 'Practitioner.yaml'
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type:
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description: |-
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A code representing of the style of consult:
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* N - note, generally made without the presence of the patient, for example to register that some lab value was received by mail.
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* C - journal was registered as part of a consult (the patient was present).
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* V - journal was registered during a visit to the patient's location.
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* CT - journal was registered during a phone or other tele-consult.
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* Other codes exist; depends on source system.
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type: string
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example: C
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code:
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description: |-
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If present, a short code representing a specific kind of action, such as a referral (`VER` - from dutch _Verwijzing_),
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`H` for medication recipe refill (dutch: _Herhaalrecept_), `REC` for prescribing a recipe, `LAB` for processing laboratory results,
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or `BVO` for a nationally organized checkup such as for Cervical Cancer (from dutch: _Bevolkingsonderzoek_).
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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),
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nor do they use standardized codes for this concept.
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type: string
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example: REC
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