| 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 |
| Other Details (Language Independent) |
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| 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 |
| 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. 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_ |
| Subsections | Subsections: Further detail. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| 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. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Subsections | Subsections : Further detail. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| 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. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Subsections | Subsections: * Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| P | P: Plans made or procedures carried out. |
| Planned actions | Planned actions : Actions which are planned or have been instructed. e.g orders. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Actions taken | Actions taken: Actions which have been undertaken e.g. medication immediately administered. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Administrative notes | Administrative notes: Administrative notes. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Subsections | Subsections: Further detail Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| E | E: Educational components offered. |
| Planned educational activities | Planned educational activities : Patient educational resources which have been ordered or planned. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Educational activities | Educational activities: Patient-centrededucational resources which have been delivered e.g. smoking cessation leaflet given. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Other contributors | Ian McNicoll Ocean Informatics |
| Translators |