ARCHETYPE SOAP (openEHR-EHR-SECTION.soap.v0)

ARCHETYPE IDopenEHR-EHR-SECTION.soap.v0
ConceptSOAP
DescriptionProblem-oriented heading in the record of the problem presented by the patient or client.
UseFor structured problem oriented records.
PurposeFor SOAP 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
Copyright© openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2006-06-27
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2006-06-27
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=openEHR Foundation, 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=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=F61FA60E31C5718138585F80B284D444, build_uid=ebe9f790-b14a-4ed9-a576-116d3bfe959b, revision=0.0.1-alpha}
Keywordssubjective, objective, assessment, plan, education, problem, oriented
Lifecyclein_development
UIDc4ef831a-deaa-3968-97d9-fb3744e9394e
Language useden
Citeable Identifier1051.32.505
Revision Number0.0.1-alpha
AllArchetype [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, freshEHR Clinical Informatics, originalLanguage=en, translators=
  • Portuguese (Brazil): Adriana Kitajima, Débora Farage, Fernanda Maia, Laíse Figueiredo, Marivan Abrahão, Osmeire Sanzovo, Core Consulting, Sanzovo & Chamelette, contato@coreconsulting.com.br, sanzovo.consultoria@gmail.com, Hospital Alemão Oswaldo Cruz (HAOC)

  • , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={state=[], content=[], capabilities=[], relationships=[], activities=[], events=[], contacts=[], description=[], target=[], context=[], identities=[], protocol=[], other_participations=[], 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null]], details=[], provider=[], source=[], ism_transition=[], data=[], credentials=[]}, 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 of 0 items, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]