Study of standard soap education effectiveness on correct progress note registering in medical records among surgical residents

摘要

Background & Objectives: Medical records are among the most valuable tools for the evaluation of service quality of care organizations. Generally, a course disease shows the latest daily status of patients. This research aimed to determine the effect of blended learning (standard SOAP method) on the accurate disease course documentation in medical records of patients by assistants of general surgery. Materials and Methods: This quasi-experimental research was performed with the cooperation of 10 first to fourth-year assistants of general surgery in Shahid Modarres Hospital affiliated with Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2016. Samples included medical records of patients selected by randomized sampling. In total, 412 medical records were evaluated before the intervention in terms of disease course documentation using a questionnaire designed based on medical documentation standard (disease course based on the SOAP) of the ministry of health, treatment, and medical education. In addition, 420 medical records were assessed after the intervention, which included education of standard notes on accurate disease course documentation based on SOAP through peer-to-peer problem solving and using emails (blended learning). Data analysis was performed in SPSS version 18.5 using paired t-test and McNemar test for quantitative and qualitative binary nominal variables, respectively. Results: In this research, a significant difference was observed before and after education based on the standard SOAP in terms of disease course documentation of patients upon admission, during treatment and at discharge (P=0.005). Moreover, a significant difference was found between the condition of information documentation related to the physician (patient’s name, the sequence of disease course report, and time) before and after the education (P=0.005). Conclusion: According to the results of the present study, documentation of the general status, care and diagnostic measures, treatment plan and observing the standard principles in the disease course sheet of patients by the assistants of general surgery were improved after blended learning.