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  1. FHIR Specification Feedback
  2. FHIR-12676

Guidance request for GP SOAP in FHIR

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    • Icon: Change Request Change Request
    • Resolution: Unresolved
    • Icon: Medium Medium
    • FHIR Core (FHIR)
    • DSTU2
    • Patient Care
    • ClinicalImpression
    • Clinical Summary Module
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    • Enhancement

    Description

      Cross-posting from GP contact report on chat-fhir.org:

      When you visit a GP he usually does some structured reporting following the Subjective, Objective, Evaluation/Assessment, Plan method. All 4 are principally text based, but S and A might be associated with a code (ICPC-1-NL for us), O might be replaced with Observations, and P might be e.g. a CarePlan, MedicationOrder or Procedure.

      S-O-A-P are grouped around a problem. If you come in with two problems (pain in ear and nasty cough) then two groups of S-O-A-P will exist, associated with the same Encounter.

      How does this play out in FHIR? It feels like we're missing an EncounterReport resource, and we could use Composition as fallback.

      The initial reaction I got from Lloyd pointed me to ClinicalImpression, but the scope of that resource does not lead me to believe that is correct.

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            Unassigned Unassigned
            ahenket Alexander Henket
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              Created:
              Updated: