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.
Sang Tian
,
Liu Xiaoyu
,
Wang Yuyan
,
Qi Jianguang
,
Zhang Xin
. Application and assessment of SOAP notes on the evaluation of medical student in pediatric department[J]. Chinese Journal of Medical Education, 2018
, 38(6)
: 865
-869
.
DOI: 10.3760/cma.j.issn.1673-677X.2018.06.015
[1] Gliatto P, Philip Masters P, Karani R. Medical student documentation in the medical record: Is it a liability?[J] Mount Sinai Journal of Medicine, 2009,76(4):357-364. DOI:10.1002/msj.20130.
[2] Varpio L, Rashotte J, Day K, et al. The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity[J].International Journal of Medical Informatics,2015,84(12):1019-1028. DOI:10.1016/j.ijmedinf.2015.09.004.
[3] 邢洁,黄淑萍,张洁.SOAP临床思维模式在药学服务中的应用[J].天津药学,2017, 29(4):43-44.
[4] 周朝生,唐维桢,徐刚,等.临床路径结合SOAP评估在临床康复教学中的应用[J]. 中国康复,2017,32(2):172-173.DOI:10.3870/zgkf.2017.02.028.
[5] 王雪强,王茹,陈佩杰.SOAP评估记录法在康复治疗教学中的应用[J].中国组织工程研究,2015,19(5):805-809.DOI:10.3969/j.issn.2095-4344.2015.05.026.
Wang XQ, Wang R, Chen PJ. Application of SOAP assessment note to rehabilitation therapy teaching[J].Chinese Journal of Tissue Engineering Research,2015,19(5):805-809.DOI:10.3969/j.issn.2095-4344.2015.05.026.
[6] Seo JH, Kong HH, Im SJ, et al. A pilot study on the evaluation of medical student documentation: Assessment of SOAP notes[J]. Korean Journal of Medical Education,2016,28(2):237-241. DOI:10.3946/kjme.2016.26.