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
Copyright© openEHR Foundation
AuthorsIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 27/06/2006
Other Details LanguageIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 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 Identifier1075.67.750
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Vsi neizrecno izključeni arhetipi
Izključi:
openEHR-EHR-OBSERVATION.exam.v1 in specializacije ali
openEHR-EHR-OBSERVATION.heart_rate.v1 in specializacije ali
openEHR-EHR-OBSERVATION.height.v1 in specializacije ali
openEHR-EHR-OBSERVATION.body_temperature.v1 in specializacije ali
openEHR-EHR-OBSERVATION.body_weight.v1 in specializacije ali
openEHR-EHR-OBSERVATION.urinalysis.v1 in specializacije ali
openEHR-EHR-OBSERVATION.blood_pressure.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001]/items[at0007], code=at0007, itemType=SLOT, level=2, text=Subsections, description=Further detail., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, extendedValues=null]], protocol=[], target=[]}, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi
Izključi:
openEHR-EHR-OBSERVATION.exam.v1 in specializacije ali
openEHR-EHR-OBSERVATION.heart_rate.v1 in specializacije ali
openEHR-EHR-OBSERVATION.height.v1 in specializacije ali
openEHR-EHR-OBSERVATION.body_temperature.v1 in specializacije ali
openEHR-EHR-OBSERVATION.body_weight.v1 in specializacije ali
openEHR-EHR-OBSERVATION.urinalysis.v1 in specializacije ali
openEHR-EHR-OBSERVATION.blood_pressure.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001]/items[at0007], code=at0007, itemType=SLOT, level=2, text=Subsections, description=Further detail., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, 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=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Vključi:
Vsi neizrecno izključeni arhetipi, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]