ARCHETYPE SOAP (openEHR-EHR-SECTION.soap.v1)

ARCHETYPE IDopenEHR-EHR-SECTION.soap.v1
ConceptSOAP
DescriptionProblem-oriented heading in the record of the problem presented by the patient or client
UseFor structured problem oriented records
PurposeFor SOAP(E) headings in the record based on the problem oriented recording style of Lawrence Weed.
ReferencesWeed 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
Copyrightcopyright (c) 2009 openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 27/06/2006
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 27/06/2006
OtherDetails Language Independent{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, MD5-CAM-1.0.1=A319FA637A6E6F7A2DA221F56081036A}
Keywordssubjective, objective, assessment, plan, education, problem, oriented
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.339
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openEHR-EHR-OBSERVATION.body_temperature.v1 and specialisations Or
openEHR-EHR-OBSERVATION.body_weight.v1 and specialisations Or
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openEHR-EHR-OBSERVATION.heart_rate.v1 and specialisations Or
openEHR-EHR-OBSERVATION.height.v1 and specialisations Or
openEHR-EHR-OBSERVATION.body_temperature.v1 and specialisations Or
openEHR-EHR-OBSERVATION.body_weight.v1 and specialisations Or
openEHR-EHR-OBSERVATION.urinalysis.v1 and specialisations Or
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All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0013], code=at0013, itemType=SLOT, level=2, text=Actions taken, description=Actions which have been undertaken e.g. medication immediately administered., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0015], code=at0015, itemType=SLOT, level=2, text=Administrative notes, description=Administrative notes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=Include:
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