KMID : 0381520160280020237
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Korean Journal of Medical Education 2016 Volume.28 No. 2 p.237 ~ p.241
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A pilot study on the evaluation of medical student documentation: assessment of SOAP notes
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Seo Ji-Hyun
Kong Hyun-Hee Im Sun-Ju Roh Hye-Rin Kim Do-Kyong Bae Hwa-Ok Oh Young-Rim
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Abstract
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Purpose: The purpose of this study was evaluation of the current status of medical students' documentation of patient medical records.
Methods: We checked the completeness, appropriateness, and accuracy of 95 Subjective-Objective-Assessment-Plan (SOAP) notes documented by third-year medical students who participated in clinical skill tests on December 1, 2014. Students were required to complete the SOAP note within 15 minutes of an standard patient (SP)-encounter with a SP complaining rhinorrhea and warring about meningitis.
Results: Of the 95 SOAP notes reviewed, 36.8% were not signed. Only 27.4% documented the patient¡¯s symptoms under the Objective component, although all students completed the Subjective notes appropriately. A possible diagnosis was assessed by 94.7% students. Plans were described in 94.7% of the SOAP notes. Over half the students planned workups (56.7%) for diagnosis and treatment (52.6%). Accurate documentation of the symptoms, physical findings, diagnoses, and plans were provided in 78.9%, 9.5%, 62.1%, and 38.0% notes, respectively.
Conclusion: Our results showed that third-year medical students¡¯ SOAP notes were not complete, appropriate, or accurate. The most significant problems with completeness were the omission of students¡¯ signatures, and inappropriate documentation of the physical examinations conducted. An education and assessment program for complete and accurate medical recording has to be developed.
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KEYWORD
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Medical records, Documentation, Medical students
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