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实习医生辅导期间的 SOAP 病历记录:学生表现评估。

SOAP Notes During APPEs: Assessment of Student Performance.

机构信息

44254Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA.

471068Touro College of Pharmacy, NY, USA.

出版信息

J Pharm Pract. 2021 Aug;34(4):665-668. doi: 10.1177/0897190019885274. Epub 2019 Nov 6.

Abstract

OBJECTIVES

To evaluate and compare students' ability to perform in each area of the subjective, objective, assessment, and plan (SOAP) note during advanced pharmacy practice experiences (APPEs) within an academic year. This study also aimed to compare the quality of SOAP notes between semesters: summer (1-3 rotation blocks), fall (4-6 rotation blocks), and spring (7-9 rotation blocks).

METHODS

During internal medicine and acute-care APPEs, students were required to submit a minimum of 2 SOAP notes. Each SOAP note was assessed by a full-time faculty member at a College of Pharmacy. Students were rated on the ability to perform in each area of the SOAP note using a rubric with a scale of 1 to 5 (1 = unacceptable/needs significant improvement, 5 = exemplary). This study was granted exempt approval by the Long Island University institutional review board.

RESULTS

Quality of the SOAP note summer versus fall versus spring rotations: Thirty-four SOAP notes were assessed during the summer, 48 SOAP notes were assessed during the fall, and 46 SOAP notes were assessed during the spring. Students performed similarly regardless of the semester they took for "subjective/objective, assess, and plan." All values were nonstatistically significant. Performance on SOAP note #1 versus SOAP note # 2: On overall rubrics for SOAP notes 1 versus SOAP notes 2, students did better on SOAP notes 2 after feedback, and an opportunity to improve was provided. There were statistically significant differences on all areas of SOAP note "subjective/objective, assess, and plan." : Overall, students performed adequately on the SOAP note activity during APPE rotations. Students performed similarly regardless of the semester/time when students took the APPEs during an academic year.

摘要

目的

在一个学年的药学实践经验(APPE)中,评估和比较学生在主观、客观、评估和计划(SOAP)记录的各个领域的表现能力。本研究还旨在比较两个学期的 SOAP 记录质量:夏季(1-3 个轮转块)、秋季(4-6 个轮转块)和春季(7-9 个轮转块)。

方法

在内科和急症护理 APPE 中,学生需要提交至少 2 份 SOAP 记录。每位学生的 SOAP 记录都由药学院的全职教师进行评估。学生在 SOAP 记录的各个领域的表现能力评分使用 1 到 5 分的评分量表(1=不可接受/需要重大改进,5=优秀)。本研究获得了长岛大学机构审查委员会的豁免批准。

结果

SOAP 记录质量夏季与秋季与春季轮转的比较:夏季评估了 34 份 SOAP 记录,秋季评估了 48 份 SOAP 记录,春季评估了 46 份 SOAP 记录。无论学生在哪个学期参加“主观/客观、评估和计划”,学生的表现都相似。所有值均无统计学意义。SOAP 记录 1 与 SOAP 记录 2 的比较:在 SOAP 记录 1 与 SOAP 记录 2 的整体评分中,学生在获得反馈和改进机会后,在 SOAP 记录 2 上的表现更好。在 SOAP 记录的“主观/客观、评估和计划”的所有领域都存在统计学上的显著差异。总体而言,学生在 APPE 轮转期间的 SOAP 记录活动中表现良好。学生在整个学年中参加 APPE 的学期/时间方面表现相似。

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