目的 分析儿科学见习医学生限时书写的"主观—客观—评估—计划"(subjective-objective-assessment-plan,SOAP)格式病历记录的优缺点,提出改进建议并进行反馈.方法 选择北京大学医学部2012级八年制临床医学专业五年级41名学生为研究对象,在儿科学见习过程中以真实病例完成一次SOAP格式书写,分别由2名教师根据自行设计的评分标准进行独立评分(满分30分),并通过问卷调查方式了解学生的反馈.对教师之间评分进行一致性评价,对学生评分和反馈情况进行统计学分析.结果 41份SOAP格式病历记录中,完整性方面有48.8％(20/41)和53.7％(22/41)的病历未记录患者姓名和日期.SOAP 4个大项中,除1名学生在plan部分未书写任何内容外,其余40名学生在所有4个项目中均有内容书写.SOAP 4大项的平均得分分别为6.80、5.69、3.35和3.92.在反馈的自我感觉部分,感到可提高和不满意者的总分(23.30±2.71)高于感到满意者的总分(21.56±2.18),两者差异具有统计学意义(t=2.133,P=0.039).结论 SOAP格式病历书写情况不尽如人意,尚有很大提高空间.相对于书本知识,SOAP格式病历书写中更需要加强的项目是基本信息、重要阴性病史、症状以及对鉴别诊断有意义的子项目.%Objective To evaluate the current status of medical students' documentation of patient medical records and to investigate their feedback of the assessment. Methods The subjective-objective-assessment-plan ( SOAP ) notes are documented by 41 students of grade 2012 in grade five of 8-year clmical medicine major of Peking University Health Science Center, who were rotating in pediatric department were checked by two teachers. Students were required to complete the SOAP note within 30 minutes of a real patient. The completeness, appropriateness, and accuracy of SOAP notes were also analyzed. Reliability was checked by Cronbach'sαscore. A questionnaire was conduted to collect feedback from students. Results No documentation of patients' names and date was observed in 48. 8％ and 53. 7％ of the 41 SOAP notes reviewed. Forty students described all four parts of the notes except that one student didn't fill any content in part four (plan). The ratio of average score to total score of subjective, objective, assessment and plan was 6. 80, 5. 69, 3. 35, 3. 92, respectively. It was worth noting that in the self-perception part of feedback, the total score (23. 30±2. 71) of those who feel unsatisfied with their performances was higher than that ( 21. 56 ± 2. 18 ) of the satisfied ones. The difference was statistically significant (t=2. 133,P=0. 039). Furthermore, the rank of SOAP was highly related to the ranks of other forms of exams. Conclusions The most significant problems with completeness were the omission of patients' names and date. The items that need to be improved in SOAP writing are basic information and important negative medical history, symptoms, and meaningful sub-items for differential diagnosis.
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