archetype (adl_version=1.4)
	openEHR-EHR-SECTION.soap.v1

concept
	[at0000]	-- SOAP
language
	original_language = <[ISO_639-1::en]>
description
	original_author = <
		["name"] = <"Sam Heard">
		["organisation"] = <"Ocean Informatics">
		["email"] = <"sam.heard@oceaninformatics.com">
		["date"] = <"27/06/2006">
	>
	details = <
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"For SOAP(E) headings in the record based on the problem oriented recording style of Lawrence Weed.">
			use = <"For structured problem oriented records">
			keywords = <"subjective", "objective", "assessment", "plan", "education", "problem", "oriented">
			misuse = <"">
			copyright = <"copyright (c) 2009 openEHR Foundation">
		>
	>
	lifecycle_state = <"AuthorDraft">
	other_contributors = <"Ian McNicoll Ocean Informatics", ...>
	other_details = <
		["MD5-CAM-1.0.1"] = <"A319FA637A6E6F7A2DA221F56081036A">
		["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">
	>

definition
	SECTION[at0000] matches {	-- SOAP
		items cardinality matches {0..*; unordered} matches {
			SECTION[at0001] occurrences matches {0..1} matches {	-- S
				items cardinality matches {0..*; unordered} matches {
					allow_archetype OBSERVATION[at0006] occurrences matches {0..*} matches {	-- Story and reports from the person and others 
						include
							archetype_id/value matches {/.*/}
						exclude
							archetype_id/value matches {/openEHR-EHR-OBSERVATION\.exam(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-OBSERVATION\.heart_rate(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-OBSERVATION\.height(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-OBSERVATION\.body_temperature(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-OBSERVATION\.body_weight(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-OBSERVATION\.urinalysis(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-OBSERVATION\.blood_pressure(-[a-zA-Z0-9_]+)*\.v1/}
					}
					allow_archetype SECTION[at0007] occurrences matches {0..1} matches {	-- Subsections
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
			SECTION[at0002] occurrences matches {0..1} matches {	-- O
				items cardinality matches {0..*; unordered} matches {
					allow_archetype OBSERVATION[at0008] occurrences matches {0..*} matches {	-- Observations and physical exam 
						include
							archetype_id/value matches {/.*/}
					}
					allow_archetype SECTION[at0009] occurrences matches {0..1} matches {	-- Subsections 
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
			SECTION[at0003] occurrences matches {0..1} matches {	-- A
				items cardinality matches {0..*; unordered} matches {
					allow_archetype EVALUATION[at0010] occurrences matches {0..*} matches {	-- Assessment, summary and diagnoses 
						include
							archetype_id/value matches {/.*/}
					}
					allow_archetype SECTION[at0011] occurrences matches {0..1} matches {	-- Subsections
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
			SECTION[at0004] occurrences matches {0..1} matches {	-- P
				items cardinality matches {0..*; unordered} matches {
					allow_archetype INSTRUCTION[at0012] occurrences matches {0..*} matches {	-- Planned actions 
						include
							archetype_id/value matches {/.*/}
					}
					allow_archetype ACTION[at0013] occurrences matches {0..*} matches {	-- Actions taken
						include
							archetype_id/value matches {/.*/}
					}
					allow_archetype ADMIN_ENTRY[at0015] occurrences matches {0..*} matches {	-- Administrative notes
						include
							archetype_id/value matches {/.*/}
					}
					allow_archetype SECTION[at0014] occurrences matches {0..1} matches {	-- Subsections
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
			SECTION[at0005] occurrences matches {0..1} matches {	-- E
				items cardinality matches {0..*; unordered} matches {
					allow_archetype INSTRUCTION[at0016] occurrences matches {0..*} matches {	-- Planned educational activities 
						include
							archetype_id/value matches {/.*/}
					}
					allow_archetype ACTION[at0017] occurrences matches {0..*} matches {	-- Educational activities
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
		}
	}

ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"SOAP">
					description = <"Problem-oriented heading in the record of the problem presented by the patient or client">
				>
				["at0001"] = <
					text = <"S">
					description = <"The subjective findings or story told by the person.">
				>
				["at0002"] = <
					text = <"O">
					description = <"The objective findings or observations made by the clinician.">
				>
				["at0003"] = <
					text = <"A">
					description = <"The assessment made by the clinician.">
				>
				["at0004"] = <
					text = <"P">
					description = <"Plans made or procedures carried out.">
				>
				["at0005"] = <
					text = <"E">
					description = <"Educational components offered.">
				>
				["at0006"] = <
					text = <"Story and reports from the person and others ">
					description = <"Subjective clinical history taken from the patient or others.">
				>
				["at0007"] = <
					text = <"Subsections">
					description = <"Further detail.">
				>
				["at0008"] = <
					text = <"Observations and physical exam ">
					description = <"Clinical findings arrived at through observation or physical examination.">
				>
				["at0009"] = <
					text = <"Subsections ">
					description = <"Further detail.">
				>
				["at0010"] = <
					text = <"Assessment, summary and diagnoses ">
					description = <"Summative assessments or evaluations of the issues presented by the patient, including diagnoses.">
				>
				["at0011"] = <
					text = <"Subsections">
					description = <"*">
				>
				["at0012"] = <
					text = <"Planned actions ">
					description = <"Actions which are planned or have been instructed. e.g orders.">
				>
				["at0013"] = <
					text = <"Actions taken">
					description = <"Actions which have been undertaken e.g. medication immediately administered.">
				>
				["at0014"] = <
					text = <"Subsections">
					description = <"Further detail">
				>
				["at0015"] = <
					text = <"Administrative notes">
					description = <"Administrative notes.">
				>
				["at0016"] = <
					text = <"Planned educational activities ">
					description = <"Patient educational resources which have been ordered or planned.">
				>
				["at0017"] = <
					text = <"Educational activities">
					description = <"Patient-centrededucational resources which have been delivered e.g. smoking cessation leaflet given.">
				>
			>
		>
	>