| ARCHETYPE ID | openEHR-EHR-SECTION.soap.v1 |
|---|---|
| Concept | SOAP |
| Description | Problem-oriented heading in the record of the problem presented by the patient or client |
| Use | For structured problem oriented records |
| Purpose | For SOAP(E) headings in the record based on the problem oriented recording style of Lawrence Weed. |
| References | Weed LL. Medical records that guide and teach. New Engl J Med: 1987; 278:593-9 and 278:652-657 Weed LL Medical records, medical education and patient care. Press of the Case Western Reserve University, 1969 http://www.prorec.it/documenti/EPR_EHR/NHS-Update-POMR-SOAP.doc |
| Copyright | copyright (c) 2009 openEHR Foundation |
| Authors | Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 27/06/2006 |
| Other Details Language | Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 27/06/2006 |
| Other Details (Language Independent) |
|
| Keywords | subjective, objective, assessment, plan, education, problem, oriented |
| Lifecycle | AuthorDraft |
| Language used | en |
| Citeable Identifier | 1013.1.339 |
| items | |
| S | S: The subjective findings or story told by the person. |
| Story and reports from the person and others | Story and reports from the person and others : Subjective clinical history taken from the patient or others. Include: All not explicitly excluded archetypes Exclude: openEHR-EHR-OBSERVATION.exam.v1 and specialisations or openEHR-EHR-OBSERVATION.heart_ openEHR-EHR-OBSERVATION.height.v1 and specialisations or openEHR-EHR-OBSERVATION.body_ openEHR-EHR-OBSERVATION.body_ openEHR-EHR-OBSERVATION.urinalysis.v1 and specialisations or openEHR-EHR-OBSERVATION.blood_ |
| Subsections | Subsections: Further detail. Include: All not explicitly excluded archetypes |
| O | O: The objective findings or observations made by the clinician. |
| Observations and physical exam | Observations and physical exam : Clinical findings arrived at through observation or physical examination. Include: All not explicitly excluded archetypes |
| Subsections | Subsections : Further detail. Include: All not explicitly excluded archetypes |
| A | A: The assessment made by the clinician. |
| Assessment, summary and diagnoses | Assessment, summary and diagnoses : Summative assessments or evaluations of the issues presented by the patient, including diagnoses. Include: All not explicitly excluded archetypes |
| Subsections | Subsections: * Include: All not explicitly excluded archetypes |
| P | P: Plans made or procedures carried out. |
| Planned actions | Planned actions : Actions which are planned or have been instructed. e.g orders. Include: All not explicitly excluded archetypes |
| Actions taken | Actions taken: Actions which have been undertaken e.g. medication immediately administered. Include: All not explicitly excluded archetypes |
| Administrative notes | Administrative notes: Administrative notes. Include: All not explicitly excluded archetypes |
| Subsections | Subsections: Further detail Include: All not explicitly excluded archetypes |
| E | E: Educational components offered. |
| Planned educational activities | Planned educational activities : Patient educational resources which have been ordered or planned. Include: All not explicitly excluded archetypes |
| Educational activities | Educational activities: Patient-centrededucational resources which have been delivered e.g. smoking cessation leaflet given. Include: All not explicitly excluded archetypes |
| Other contributors | Ian McNicoll Ocean Informatics |
| Translators |