关键词: 病历记录, 医学生, 儿科学, 应用, 评价

Abstract: Objective To evaluate the current status of medical students' documentation of patient medical records and to investigate their feedback of the assessment. Methods The subjective-objective-assessment-plan (SOAP) notes are documented by 41 students of grade 2012 in grade five of 8-year clmical medicine major of Peking University Health Science Center, who were rotating in pediatric department were checked by two teachers. Students were required to complete the SOAP note within 30 minutes of a real patient. The completeness, appropriateness, and accuracy of SOAP notes were also analyzed. Reliability was checked by Cronbach's α score. A questionnaire was conduted to collect feedback from students. Results No documentation of patients' names and date was observed in 48.8% and 53.7% of the 41 SOAP notes reviewed. Forty students described all four parts of the notes except that one student didn't fill any content in part four (plan). The ratio of average score to total score of subjective, objective, assessment and plan was6.80, 5.69, 3.35, 3.92, respectively. It was worth noting that in the self-perception part of feedback, the total score (23.30±2.71) of those who feel unsatisfied with their performances was higher than that (21.56±2.18) of the satisfied ones. The difference was statistically significant (t=2.133,P=0.039). Furthermore, the rank of SOAP was highly related to the ranks of other forms of exams. Conclusions The most significant problems with completeness were the omission of patients' names and date. The items that need to be improved in SOAP writing are basic information and important negative medical history, symptoms, and meaningful sub-items for differential diagnosis.

Key words: Medical records, Medical students, Pediatrics, Application, Assessment