You cannot select more than 25 topics
Topics must start with a letter or number, can include dashes ('-') and can be up to 35 characters long.
80 lines
3.9 KiB
YAML
80 lines
3.9 KiB
YAML
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"
|
|
text:
|
|
description: |-
|
|
The journal text as typed by the practicioner. Can, obviously, be quite long, and can contain newlines.
|
|
type: string
|
|
soap:
|
|
description: |-
|
|
Most medical systems separate journal text using the SOAP system (dutch: _SOEP_):
|
|
* `S`: Subjective (dutch: _Subjectief_) - A (transcription of the) description of the medical issue by the patient themselves
|
|
* `O`: Objective (dutch: _Objectief_) - The description of the medical issue as observed by a trained medical practicioner
|
|
* `A`: Analysis (dutch: _Evaluatie_) - The diagnosis.
|
|
* `P`: Plan (dutch: _Plan_) - The course of action to take, or notes about next steps to deal with the issue raised in this journal entry.
|
|
* `X`: Unknown - this text does not fit any of the 4 SOAP categories, or this represents journal text not written using the SOAP system.
|
|
|
|
Any of these can be missing. For example, for tele-health various practices have internal policy to leave Objective blank, especially if
|
|
no video or pictures are made, because no medical professional is on hand to make an objective report about the stated issues.
|
|
|
|
Often newlines appear in weird places, or newlines are not conveyed even if typed by the practicioner; these are limitations in the source system.
|
|
type: string
|
|
enum:
|
|
- S
|
|
- O
|
|
- A
|
|
- P
|
|
- X
|
|
example: S
|
|
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
|