| ARCHETYPE ID | openEHR-EHR-SECTION.soap.v0 |
|---|---|
| Concept | SOAP headings |
| Description | Acronym for a group of headings used to aid recording of consistent, problem-oriented notes in a patient's health record. |
| Use | Use to provide a framework and design guidance for consistent modelling of SOAP(E) content within a template representing problem-oriented clinical notes. |
| Purpose | To provide a framework and design guidance for consistent modelling of SOAP content within a template representing problem-oriented clinical notes. |
| References | Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. doi: 10.1056/NEJM196803142781105. PMID: 5637758. Weed LL. Medical records, medical education and patient care. Press of the Case Western Reserve University, 1970. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2020-10-28 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2020-10-28 |
| Other Details (Language Independent) |
|
| Keywords | subjective, objective, assessment, plan, education, problem, oriented |
| Lifecycle | in_development |
| UID | c4ef831a-deaa-3968-97d9-fb3744e9394e |
| Language used | en |
| Citeable Identifier | 1246.145.2802 |
| Revision Number | 0.0.1-alpha |
| items | |
| Subjective (S) | Subjective (S): The subjective component, usually focused on the presenting complaint, history of present illness, relevant medical history and review of system. For example: EVALUATION.reason_for_encounter and OBSERVATION.story. |
| Objective (O) | Objective (O): The objective component, usually focused on observations, measurements, examination findings and diagnostic test results. For example: OBSERVATION.exam, OBSERVATION.blood_pressure and OBSERVATION.laboratory_test_result. |
| Assessment (A) | Assessment (A): The assessment component, usually focused on conclusions and synopses about progress or change. For example: EVALUATION.differential_diagnoses, EVALUATION.problem_diagnosis, and EVALUATION.clinical_synopsis. |
| Plan (P) | Plan (P): The plan component, usually focused on future investigations and treatment, goals of therapy and monitoring. For example: INSTRUCTION.service_request, INSTRUCTION.medication_order, and INSTRUCTION.health_education_request. |
| Other contributors | Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Sam Heard, Ocean Informatics, Australia |
| Translators |