SOAP Note Bundle

Bundle Metadata

• ID: soap-note-bundle
• Last Updated: 2024-01-15T11:30:00Z
• Profile: HL7 Bundle
• Type: collection
• Timestamp: 2024-01-15T11:30:00Z

Entries

Encounter

• Full URL: urn:uuid:encounter-example-encounter
• Resource Type: Encounter
• ID: example-encounter
• Status: finished
• Class:
  • System: v3-ActCode
  • Code: AMB
  • Display: ambulatory
• Type:
  • Coding:
    • System: snomed.info
    • Code: 162673000
    • Display: General examination of patient (procedure)
• Subject:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Participant:
  • Type:
    • Coding:
      • System: v3-ParticipationType
      • Code: PPRF
      • Display: primary performer
  • Individual:
    • Reference: Practitioner/dr-alice-smith
    • Display: Dr. Alice Smith
• Period:
  • Start: 2024-01-15T09:00:00Z
  • End: 2024-01-15T10:30:00Z

Observation: Subjective Fatigue

• Full URL: urn:uuid:obs-subjective-fatigue
• Resource Type: Observation
• ID: obs-subjective-fatigue
• Status: final
• Category:
  • Coding:
    • System: observation-category
    • Code: survey
    • Display: Survey
• Code:
  • Coding:
    • System: loinc.org
    • Code: 75325-1
    • Display: Symptom
  • Text: Fatigue
• Subject:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Encounter:
  • Reference: Encounter/example-encounter
  • Display: Office visit
• Effective Date Time: 2024-01-15T09:15:00Z
• Performer:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Value String: Patient reports feeling lethargic and fatigued for the past week with associated epigastric discomfort.

Observation: Objective Heart Rate

• Full URL: urn:uuid:obs-objective-heart-rate
• Resource Type: Observation
• ID: obs-objective-heart-rate
• Status: final
• Category:
  • Coding:
    • System: observation-category
    • Code: vital-signs
    • Display: Vital Signs
• Code:
  • Coding:
    • System: loinc.org
    • Code: 8867-4
    • Display: Heart rate
• Subject:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Encounter:
  • Reference: Encounter/example-encounter
  • Display: Office visit
• Effective Date Time: 2024-01-15T09:20:00Z
• Performer:
  • Reference: Practitioner/dr-alice-smith
  • Display: Dr. Alice Smith
• Value Quantity:
  • Value: 112
  • Unit: beats/min
  • System: unitsofmeasure.org
  • Code: {Beats}/min

Clinical Impression

• Full URL: urn:uuid:clinical-impression-assessment
• Resource Type: ClinicalImpression
• ID: clinical-impression-assessment
• Status: completed
• Subject:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Encounter:
  • Reference: Encounter/example-encounter
  • Display: Office visit
• Date: 2024-01-15T10:00:00Z
• Assessor:
  • Reference: Practitioner/dr-alice-smith
  • Display: Dr. Alice Smith
• Description: Patient presents with fatigue and epigastric discomfort. Physical exam notable for elevated heart rate. Symptoms consistent with gastritis.
• Supporting Info:
  • Reference: Observation/obs-subjective-fatigue
  • Display: Patient-reported fatigue
  • Reference: Observation/obs-objective-heart-rate
  • Display: Elevated heart rate
• Note:
  • Text: Assessment: Symptoms of fatigue, epigastric discomfort, and tachycardia are consistent with gastritis. Differential diagnosis includes peptic ulcer disease. Recommend H. pylori testing to guide treatment. Will initiate empiric therapy pending lab results.

Condition: Gastritis

• Full URL: urn:uuid:condition-gastritis
• Resource Type: Condition
• ID: condition-gastritis
• Clinical Status:
  • Coding:
    • System: condition-clinical
    • Code: active
    • Display: Active
• Verification Status:
  • Coding:
    • System: condition-ver-status
    • Code: confirmed
    • Display: Confirmed
• Category:
  • Coding:
    • System: condition-category
    • Code: encounter-diagnosis
    • Display: Encounter Diagnosis
• Code:
  • Coding:
    • System: icd-10-cm
    • Code: K29.70
    • Display: Gastritis, unspecified, without bleeding
  • Text: Gastritis, unspecified
• Subject:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Encounter:
  • Reference: Encounter/example-encounter
  • Display: Office visit
• Onset Date Time: 2024-01-15
• Asserter:
  • Reference: Practitioner/dr-alice-smith
  • Display: Dr. Alice Smith

Service Request: Lab

• Full URL: urn:uuid:service-request-lab
• Resource Type: ServiceRequest
• ID: service-request-lab
• Status: active
• Intent: order
• Code:
  • Coding:
    • System: loinc.org
    • Code: 13958-0
    • Display: Helicobacter pylori [Presence] in Gastric fluid by Organism specific culture
  • Text: H. pylori culture
• Subject:
  • Reference: Patient/homer-simpson
  • Display: Homer Simpson
• Encounter:
  • Reference: Encounter/example-encounter
  • Display: Office visit
• Authored On: 2024-01-15T10:15:00Z
• Requester:
  • Reference: Practitioner/dr-alice-smith
  • Display: Dr. Alice Smith
• Reason Code:
  • Coding:
    • System: icd-10-cm
    • Code: K29.70
    • Display: Gastritis, unspecified, without bleeding
  • Text: Rule out H. pylori in setting of gastritis

Provenance

• Full URL: urn:uuid:provenance-note-signed
• Resource Type: Provenance
• ID: provenance-note-signed
• Target:
  • Reference: Encounter/example-encounter
  • Display: Office visit
• Recorded: 2024-01-15T11:30:00Z
• Reason:
  • Coding:
    • System: v3-ActReason
    • Code: SIGN
    • Display: Signed
• Agent:
  • Type:
    • Coding:
      • System: provenance-participant-type
      • Code: author
      • Display: Author
  • Who:
    • Reference: Practitioner/dr-alice-smith
    • Display: Dr. Alice Smith