Sando Karen R, Skoy Elizabeth, Bradley Courtney, Frenzel Jeanne, Kirwin Jennifer, Urteaga Elizabeth
Dept. of Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Gainesville, FL, United States.
Dept. of Pharmacy Practice, North Dakota State University School of Pharmacy, Fargo, ND, United States.
Curr Pharm Teach Learn. 2017 Jul;9(4):576-584. doi: 10.1016/j.cptl.2017.03.010. Epub 2017 Jun 1.
To describe current methods used to assess SOAP notes in colleges and schools of pharmacy.
Members of the American Association of Colleges of Pharmacy Laboratory Instructors Special Interest Group were invited to share assessment tools for SOAP notes. Content of submissions was evaluated to characterize overall qualities and how the tools assessed subjective, objective, assessment, and plan information.
Thirty-nine assessment tools from 25 schools were evaluated. Twenty-nine (74%) of the tools were rubrics and ten (26%) were checklists. All rubrics included analytic scoring elements, while two (7%) were mixed with holistic and analytic scoring elements. A majority of the rubrics (35%) used a four-item rating scale. Substantial variability existed in how tools evaluated subjective and objective sections. All tools included problem identification in the assessment section. Other assessment items included goals (82%) and rationale (69%). Seventy-seven percent assessed drug therapy; however, only 33% assessed non-drug therapy. Other plan items included education (59%) and follow-up (90%).
There is a great deal of variation in the specific elements used to evaluate SOAP notes in colleges and schools of pharmacy. Improved consistency in assessment methods to evaluate SOAP notes may better prepare students to produce standardized documentation when entering practice.
描述目前药学院校用于评估SOAP病历的方法。
邀请美国药学院协会实验室教师特别兴趣小组的成员分享SOAP病历的评估工具。对提交内容进行评估,以确定整体质量以及这些工具如何评估主观、客观、评估和计划信息。
对来自25所学校的39种评估工具进行了评估。其中29种(74%)工具为评分细则,10种(26%)为检查表。所有评分细则都包含分析性评分要素,其中两种(7%)将整体性和分析性评分要素混合使用。大多数评分细则(35%)采用四项评分量表。工具在评估主观和客观部分的方式上存在很大差异。所有工具在评估部分都包括问题识别。其他评估项目包括目标(82%)和基本原理(69%)。77%的工具评估药物治疗;然而,只有33%的工具评估非药物治疗。其他计划项目包括教育(59%)和随访(90%)。
药学院校用于评估SOAP病历的具体要素存在很大差异。提高评估SOAP病历的方法的一致性,可能会让学生在进入实践时更好地准备生成标准化文档。