Suppr超能文献

药学学生从 SOAP 记录转向咨询记录进行临床文档记录。

Shifting from SOAP Notes to Consult Notes for Clinical Documentation by Pharmacy Students.

机构信息

High Point University, Fred Wilson School of Pharmacy, High Point, North Carolina

High Point University, Fred Wilson School of Pharmacy, High Point, North Carolina.

出版信息

Am J Pharm Educ. 2022 Oct;86(7):8781. doi: 10.5688/ajpe8781. Epub 2021 Dec 2.

Abstract

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.

摘要

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。

相似文献

1
Shifting from SOAP Notes to Consult Notes for Clinical Documentation by Pharmacy Students.
Am J Pharm Educ. 2022 Oct;86(7):8781. doi: 10.5688/ajpe8781. Epub 2021 Dec 2.
2
Perception of electronic peer review of SOAP notes among pharmacy students enrolling in their first pharmacotherapeutics course.
Curr Pharm Teach Learn. 2019 Dec;11(12):1259-1264. doi: 10.1016/j.cptl.2019.09.005. Epub 2019 Oct 17.
3
SOAP Notes During APPEs: Assessment of Student Performance.
J Pharm Pract. 2021 Aug;34(4):665-668. doi: 10.1177/0897190019885274. Epub 2019 Nov 6.
4
Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE.
Am J Pharm Educ. 2018 Nov;82(9):6725. doi: 10.5688/ajpe6725.
5
Ambulatory care preceptors' perceptions on SOAP note writing in advanced pharmacy practice experiences (APPEs).
Curr Pharm Teach Learn. 2018 Dec;10(12):1574-1578. doi: 10.1016/j.cptl.2018.09.002. Epub 2018 Sep 13.
8
Assessment of SOAP note evaluation tools in colleges and schools of pharmacy.
Curr Pharm Teach Learn. 2017 Jul;9(4):576-584. doi: 10.1016/j.cptl.2017.03.010. Epub 2017 Jun 1.
9
Evaluation of SOAP note performance in a pharmacotherapeutics course after implementation of a peer-review process.
Curr Pharm Teach Learn. 2022 Jul;14(7):870-874. doi: 10.1016/j.cptl.2022.06.024. Epub 2022 Jun 25.
10
Assessment of pharmacy students' patient care skills using case scenarios with a SOAP note grading rubric and standardized patient feedback.
Curr Pharm Teach Learn. 2019 May;11(5):513-521. doi: 10.1016/j.cptl.2019.02.012. Epub 2019 May 3.

本文引用的文献

1
Improved learning experience with modified case studies courses in a pharmacy curriculum.
Curr Pharm Teach Learn. 2020 Oct;12(10):1224-1238. doi: 10.1016/j.cptl.2020.05.005. Epub 2020 Jun 23.
3
Use of an Interactive Online Teaching Module Improved Students' Ability to Write a Clinically Appropriate SOAP Note.
J Vet Med Educ. 2020 Dec;47(6):700-708. doi: 10.3138/jvme.0918-107r. Epub 2020 Feb 13.
4
Perception of electronic peer review of SOAP notes among pharmacy students enrolling in their first pharmacotherapeutics course.
Curr Pharm Teach Learn. 2019 Dec;11(12):1259-1264. doi: 10.1016/j.cptl.2019.09.005. Epub 2019 Oct 17.
5
SOAP Notes During APPEs: Assessment of Student Performance.
J Pharm Pract. 2021 Aug;34(4):665-668. doi: 10.1177/0897190019885274. Epub 2019 Nov 6.
6
Assessment of pharmacy students' patient care skills using case scenarios with a SOAP note grading rubric and standardized patient feedback.
Curr Pharm Teach Learn. 2019 May;11(5):513-521. doi: 10.1016/j.cptl.2019.02.012. Epub 2019 May 3.
7
Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE.
Am J Pharm Educ. 2018 Nov;82(9):6725. doi: 10.5688/ajpe6725.
8
Ambulatory care preceptors' perceptions on SOAP note writing in advanced pharmacy practice experiences (APPEs).
Curr Pharm Teach Learn. 2018 Dec;10(12):1574-1578. doi: 10.1016/j.cptl.2018.09.002. Epub 2018 Sep 13.
9
Delivery of Standardized Patient Instructions in the After-Visit Summary Reduces Telephone Calls Between Clinic Visits.
Am J Med Qual. 2018 Nov/Dec;33(6):642-648. doi: 10.1177/1062860618770043. Epub 2018 Apr 18.
10
Implementing the Pharmacists' Patient Care Process at a Public Pharmacy School.
Am J Pharm Educ. 2018 Mar;82(2):6301. doi: 10.5688/ajpe6301.

文献AI研究员

20分钟写一篇综述,助力文献阅读效率提升50倍。

立即体验

用中文搜PubMed

大模型驱动的PubMed中文搜索引擎

马上搜索

文档翻译

学术文献翻译模型,支持多种主流文档格式。

立即体验