ARCHETYPE ID | openEHR-EHR-SECTION.soap.v0 |
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 | © Nasjonal IKT HF |
Authors | Forfatternavn: Sam Heard Organisasjon: Ocean Informatics E-post: sam.heard@oceaninformatics.com Opprinnelig skrevet dato: 27/06/2006 |
Other Details Language | Forfatternavn: Sam Heard Organisasjon: Ocean Informatics E-post: sam.heard@oceaninformatics.com Opprinnelig skrevet dato: 27/06/2006 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Nasjonal IKT, 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, original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=39E9B78F6196EC8AEEF3E7E2CA4D481D, build_uid=5eadd92c-b0a6-4fdb-a338-632afd36af20, revision=0.0.1-alpha} |
Keywords | subjective, objective, assessment, plan, education, problem, oriented |
Lifecycle | in_development |
UID | a1ec984f-f1a3-4b1b-83d0-ff2e0a2884bd |
Language used | en |
Citeable Identifier | 1078.36.656 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Problem-oriented heading in the record of the problem presented by the patient or client, archetypeConceptComment=null, otherContributors=Ian McNicoll Ocean Informatics, originalLanguage=en, translators=, subjectOfData=ubegrenset, archetypeTranslationTree=null, topLevelToAshis={items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=SECTION, level=1, text=S, description=The subjective findings or story told by the person., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer Alle ikke eksplisitt ekskluderte arketyper Ekskluder: openEHR-EHR-OBSERVATION.exam.v1 og spesialiseringer eller openEHR-EHR-OBSERVATION.heart_ openEHR-EHR-OBSERVATION.height.v1 og spesialiseringer eller openEHR-EHR-OBSERVATION.body_ openEHR-EHR-OBSERVATION.body_ openEHR-EHR-OBSERVATION.urinalysis.v1 og spesialiseringer eller openEHR-EHR-OBSERVATION.blood_ Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=SECTION, level=1, text=O, description=The objective findings or observations made by the clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0008], code=at0008, itemType=SLOT, level=2, text=Observations and physical exam , description=Clinical findings arrived at through observation or physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0009], code=at0009, itemType=SLOT, level=2, text=Subsections , description=Further detail., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=SECTION, level=1, text=A, description=The assessment made by the clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003]/items[at0010], code=at0010, itemType=SLOT, level=2, text=Assessment, summary and diagnoses , description=Summative assessments or evaluations of the issues presented by the patient, including diagnoses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003]/items[at0011], code=at0011, itemType=SLOT, level=2, text=Subsections, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SECTION, level=1, text=P, description=Plans made or procedures carried out., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0012], code=at0012, itemType=SLOT, level=2, text=Planned actions , description=Actions which are planned or have been instructed. e.g orders., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0014], code=at0014, itemType=SLOT, level=2, text=Subsections, description=Further detail, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SECTION, level=1, text=E, description=Educational components offered., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0016], code=at0016, itemType=SLOT, level=2, text=Planned educational activities , description=Patient educational resources which have been ordered or planned., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Educational activities, description=Patient-centrededucational resources which have been delivered e.g. smoking cessation leaflet given., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null]], identities=[], events=[], contacts=[], activities=[], data=[], details=[], source=[], target=[], other_participations=[], ism_transition=[], credentials=[], protocol=[], state=[], content=[], context=[], description=[], provider=[], capabilities=[], relationships=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/items[at0001], code=at0001, itemType=SECTION, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=SECTION, level=1, text=S, description=The subjective findings or story told by the person., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001]/items[at0006], code=at0006, itemType=SLOT, level=2, text=Story and reports from the person and others , description=Subjective clinical history taken from the patient or others., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper Ekskluder: openEHR-EHR-OBSERVATION.exam.v1 og spesialiseringer eller openEHR-EHR-OBSERVATION.heart_ openEHR-EHR-OBSERVATION.height.v1 og spesialiseringer eller openEHR-EHR-OBSERVATION.body_ openEHR-EHR-OBSERVATION.body_ openEHR-EHR-OBSERVATION.urinalysis.v1 og spesialiseringer eller openEHR-EHR-OBSERVATION.blood_ Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=SECTION, level=1, text=O, description=The objective findings or observations made by the clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0008], code=at0008, itemType=SLOT, level=2, text=Observations and physical exam , description=Clinical findings arrived at through observation or physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0009], code=at0009, itemType=SLOT, level=2, text=Subsections , description=Further detail., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=SECTION, level=1, text=A, description=The assessment made by the clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003]/items[at0010], code=at0010, itemType=SLOT, level=2, text=Assessment, summary and diagnoses , description=Summative assessments or evaluations of the issues presented by the patient, including diagnoses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003]/items[at0011], code=at0011, itemType=SLOT, level=2, text=Subsections, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SECTION, level=1, text=P, description=Plans made or procedures carried out., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0012], code=at0012, itemType=SLOT, level=2, text=Planned actions , description=Actions which are planned or have been instructed. e.g orders., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0014], code=at0014, itemType=SLOT, level=2, text=Subsections, description=Further detail, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SECTION, level=1, text=E, description=Educational components offered., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=0..*, cardinalityText=Minimum 0 oppføringer , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0016], code=at0016, itemType=SLOT, level=2, text=Planned educational activities , description=Patient educational resources which have been ordered or planned., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Educational activities, description=Patient-centrededucational resources which have been delivered e.g. smoking cessation leaflet given., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Inkluder: Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] | , subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001]/items[at0006], code=at0006, itemType=SLOT, level=2, text=Story and reports from the person and others , description=Subjective clinical history taken from the patient or others., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Inkluder: