지원사업
학술연구/단체지원/교육 등 연구자 활동을 지속하도록 DBpia가 지원하고 있어요.
커뮤니티
연구자들이 자신의 연구와 전문성을 널리 알리고, 새로운 협력의 기회를 만들 수 있는 네트워킹 공간이에요.
논문 기본 정보
- 자료유형
- 학술저널
- 저자정보
- 발행연도
- 2016.1
- 수록면
- 237 - 241 (5page)
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초록· 키워드
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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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참고문헌 (7)
참고문헌 신청
Gliatto P / 2009 / Medical student documentation in the medical record: is it a liability / Mt Sinai J Med 76:357~364
Szauter KM / 2006 / Do students do what they write and write what they do? The match between the patient encounter and patient note / Acad Med 81(10 Suppl):S44~S47
Good Medical Practice
Association of American Medical Colleges / 1998 / Report 1. learning objectives for medical student education: guidelines for medical schools
Varpio L / 2015 / The EHR and building the patient's story: a qualitative investigation of how EHR use obstructs a vital clinical activity / Int J Med Inform 84:1019~1028
Szauter KM / 2006 / Do students do what they write and write what they do? The match between the patient encounter and patient note / Acad Med 81(10 Suppl):S44~S47
Good Medical Practice
Association of American Medical Colleges / 1998 / Report 1. learning objectives for medical student education: guidelines for medical schools
Varpio L / 2015 / The EHR and building the patient's story: a qualitative investigation of how EHR use obstructs a vital clinical activity / Int J Med Inform 84:1019~1028
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