{ "description": "The general practitioner encounter report is an S-O-A-P (Subjective, Objective, Assessment, Plan) structured report of a patient encounter. S-O-A-P is known as S-O-E-P (Subjectief, Objectief, Evaluatie, Plan) in Dutch. Each Composition.section corresponds with a letter from SOAP and may additionally be ICPC coded using the appropriate extension. If the encounter report relates to an episode of care then the association with EpisodeOfCare shall be in Composition.event.detail.", "_filename": "gp-EncounterReport.json", "package_name": "nictiz.fhir.nl.stu3.zib2017", "date": null, "derivation": "constraint", "publisher": "Nictiz", "fhirVersion": "3.0.2", "name": "gp EncounterReport", "abstract": false, "copyright": "CC0", "type": "Composition", "experimental": null, "resourceType": "StructureDefinition", "title": "gp-EncounterReport", "package_version": "2.0.4", "status": "active", "id": "ba0227ed-5855-486e-982d-43f5a936abba", "kind": "resource", "url": "http://nictiz.nl/fhir/StructureDefinition/gp-EncounterReport", "version": "2.0.2", "differential": { "element": [ { "id": "Composition", "path": "Composition", "alias": [ "Deelcontactverslag" ] }, { "id": "Composition.type.coding.system", "path": "Composition.type.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.type.coding.code", "path": "Composition.type.coding.code", "fixedCode": "67781-5" }, { "id": "Composition.encounter", "min": 1, "path": "Composition.encounter", "type": [ { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-Encounter" } ] }, { "id": "Composition.author", "path": "Composition.author", "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceProduct" }, { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-patient" }, { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-relatedperson" } ] }, { "id": "Composition.author.extension", "path": "Composition.author.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Composition.author.extension:practitionerRole", "max": "1", "path": "Composition.author.extension", "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference" } ], "sliceName": "practitionerRole" }, { "id": "Composition.title", "path": "Composition.title", "definition": "Official human-readable label for the composition. Suggested value is either episode title, or the ICPC display name on the E-entry" }, { "id": "Composition.attester.party", "path": "Composition.attester.party", "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-patient" }, { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner" }, { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-organization" } ] }, { "id": "Composition.attester.party.extension", "path": "Composition.attester.party.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Composition.attester.party.extension:practitionerRole", "max": "1", "path": "Composition.attester.party.extension", "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference" } ], "sliceName": "practitionerRole" }, { "id": "Composition.custodian", "path": "Composition.custodian", "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-organization" } ] }, { "id": "Composition.section.extension", "path": "Composition.section.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Composition.section.extension:code_icpc_1_nl", "max": "1", "path": "Composition.section.extension", "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl" } ], "sliceName": "code_icpc_1_nl" }, { "id": "Composition.section.code", "min": 1, "path": "Composition.section.code", "binding": { "strength": "required", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "CompositionSectionType" } ], "valueSetReference": { "display": "JournaalregelType", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.103.11.2--20111012000000" } } }, { "id": "Composition.section.text", "min": 1, "path": "Composition.section.text" }, { "id": "Composition.section.entry", "path": "Composition.section.entry", "definition": "A reference to data that supports this section. At minimum, there should be an entry for the gp-JournalEntry(Observation) that the section.entry.text was based on. Note that this gp-JournalEntry in turn will connect to the ICPC coding if relevant.\r\n\r\nOther references are the nl-core-episodeofcare(EpisodeOfCare) that this section relates to, a diagnostic result on the \"O\" entry, or a medication agreement or a care plan on the \"P\" entry.\r\n\r\nWhile it is possible *not* to relate to an EpisodeOfCare, this is not likely due to the episode based record keeping by GPs." } ] }, "contact": [ { "name": "Nictiz", "telecom": [ { "use": "work", "value": "info@nictiz.nl", "system": "email" } ] } ], "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Composition" }