Anatomy SOAP Notes: Integrating an essential clinical tool into the anatomy lab

Abstract

An essential component of patient care is documentation of each patient encounter. It is often said, “If it is not documented it didn’t happen.” Each encounter with a patient requires a medical record including: the patient’s symptoms, clinical signs, the diagnosis, and treatment plan. Documentation is important for continuity of care and communication between healthcare providers. This record of the patient encounter is also an important medico‐legal document. The widely adopted Subjective, Objective, Assessment, and Plan (SOAP) Note is one form of this documentation of the physician‐patient interaction.Human Gross Anatomy is the foundational course often seen as a rite of passage and one of the most memorable parts of the medical and dental students’ learning experience in the pre‐clinical years. The body donor in this course is considered the students’ first patient. To emphasize observation skills and promote record keeping of patient encounters we instituted a new activity for our medical and dental students enrolled in gross anatomy as part of the pre‐clinical curriculum. In the medical course, each “patient” encounter is documented by completion of a brief exercise (modified Anatomy SOAP note) at the conclusion of each lab dissection. A single SOAP note activity is instituted for the dental students to be completed at the conclusion of the dental anatomy course.Preliminary observations from medical student submissions indicates a collaborative effort to complete the dissections and document anatomical variations and pathologies observed during the dissections. Faculty observations note students taking a keen interest in finding any anatomical variations or pathology present in their patient. Our faculty have witnessed an increase in level of team‐work and discussion about novel findings during dissection by members of the dissection team. Students have demonstrated, in their actions in lab as well as their write‐ups, increased collaboration and greater awareness of anatomical variations and pathology present in the body donor. Specific comments regarding teamwork, attention to pathologic changes and anatomical variations include: “Team worked well together by sharing roles and responsibilities. When one person struggled with one area [of] knowledge [our] skill was shared.” “We found that our cadaver was missing a large chunk of the right cerebral hemisphere, including loss in both the parietal and temporal lobes. We believe that this was likely due to a severe stroke.” “We have a right hepatic artery coming off of our superior mesenteric artery.”At the conclusion of both medical and dental anatomy courses survey data will be evaluated for comparison of the two methods of integration of the Anatomy SOAP note exercise. The notes themselves will be evaluated for content and observed anatomical variations and pathology. Initial observations suggest improvement of collaboration in the dissection team. We also speculate that this novel activity will be a positive tool to help reinforce patient documentation and build observation skills in our students. In addition, a database of observed variations will further expose future clinicians to the critical role of normal anatomy and anatomical variations in patient care.