High Point University, Fred Wilson School of Pharmacy, High Point, North Carolina
High Point University, Fred Wilson School of Pharmacy, High Point, North Carolina.
Am J Pharm Educ. 2022 Oct;86(7):8781. doi: 10.5688/ajpe8781. Epub 2021 Dec 2.
Clinical documentation is an important element of patient care that pharmacy students traditionally learn through subjective-objective-assessment-plan (SOAP) notes. In clinical practice, pharmacists often document more succinctly, both in length and time, using formats such as consult notes. The objective of this study was to assess consult note assignments for third-year pharmacy (P3) students. Consult note assignments were implemented in a P3 skills laboratory course by converting SOAP notes to consult notes. The series began with an introduction and a practice consult note. Four graded notes were then completed throughout the semester, whereby the time allotted for writing decreased throughout the semester. To assess the series, grades and estimated time to completion were collected for each graded note. A survey given before and after the course assessed student self-confidence in overall documentation, specific elements of consult notes, and concerns related to writing. Friedman tests were used to compare grades and times. Wilcoxon signed rank tests were used to compare self-assessments. The median grades on the four consult notes were 92%, 88%, 80%, and 90%. Median times for completing each note were 75 minutes, 120 minutes, 60 minutes, and 60 minutes. Students' self-confidence in writing consult notes significantly increased, as did five of the six individual elements. The consult note assignments allowed students to practice documenting patient care in a succinct format with consideration for time efficiency. Further work should evaluate best pedagogies for teaching documentation skills and assess the impact on performance during advanced pharmacy practice experiences.
临床文档是患者护理的一个重要组成部分,药学专业的学生传统上通过主观-客观-评估-计划(SOAP)记录来学习。在临床实践中,药剂师通常使用咨询记录等格式更简洁地记录,无论是在长度还是时间上。本研究的目的是评估药学三年级(P3)学生的咨询记录作业。通过将 SOAP 记录转换为咨询记录,在 P3 技能实验室课程中实施了咨询记录作业。该系列从介绍和实践咨询记录开始。然后,在整个学期内完成了四个分级记录,整个学期的写作时间逐渐减少。为了评估该系列,收集了每个分级记录的成绩和估计完成时间。在课程前后进行的一项调查评估了学生对整体文档记录、咨询记录的具体要素以及与写作相关的问题的自我信心。使用 Friedman 检验比较成绩和时间。使用 Wilcoxon 符号秩检验比较自我评估。四个咨询记录的中位数成绩分别为 92%、88%、80%和 90%。完成每个记录的中位数时间分别为 75 分钟、120 分钟、60 分钟和 60 分钟。学生对撰写咨询记录的信心明显提高,其中六个要素中的五个也有所提高。咨询记录作业使学生能够在考虑时间效率的情况下以简洁的格式记录患者护理。进一步的工作应该评估教授文档技能的最佳教学方法,并评估其对高级药学实践经验表现的影响。