Subjective, Objective, Assessment, Plan Note Research Articles

Impact of removing group SOAP note writing from a problem-based learning course series on documentation performance during experiential rotations

Background and purposeDocumentation is a key component of pharmacy education, and SOAP (subjective, objective, assessment, plan) notes are a common framework. Learners must receive feedback, but the amount needed to achieve desired outcomes on experiential rotations is unknown. This study assessed the impact of discontinuing group-written SOAP notes in a four-course problem-based learning (PBL) series on note scores in experiential rotations. Educational activity and settingThree cohorts across five graduating classes were compared; group-written SOAP notes in four, two, and no PBL semesters. Note writing scores on inpatient medicine and ambulatory care introductory and advanced pharmacy practice experiences (IPPEs and APPEs) were compared using logistic analysis. The odds ratio (OR) of writing a “high performance” note was determined compared to the reference of zero semesters of PBL note writing. FindingsAdditional PBL SOAP note writing did not impact inpatient medicine IPPE scores; however, four semesters of note writing significantly lowered internal medicine APPE note writing scores (OR = 0.51, 95% CI = 0.31–0.84, P = .008). In contrast, two and four semesters of SOAP note writing improved ambulatory care IPPE note writing (OR = 2.33, 95% CI = 1.17–4.65, P = .02 and OR = 2.48, 95% CI = 1.47–4.16, P < .001, respectively) but there was no difference in ambulatory care APPE note scores. SummaryRemoving opportunities for group-written SOAP notes in a PBL course series minimally impacted students' performance on APPEs. Institutions may consider if current SOAP note feedback is effective in preparing learners for APPEs.

Characterization of clinical knowledge and problem-solving assessments employed in postgraduate year 1 pharmacy residency interviews.

Attainment of postgraduate year 1 (PGY1) residency positions has become increasingly competitive. Inclusion of clinical knowledge and problem-solving assessments in onsite interviews has increased in recent years. Characterization of these assessments is necessary for applicants to best prepare for interviews and for mentors to provide guidance. An online survey was emailed to program directors of PGY1 pharmacy residency programs accredited by the American Society of Health-System Pharmacists (ASHP). Data were analyzed using descriptive statistics. Chi-square and Fisher's exact tests were used to compare categorical data. The Mann-Whitney U test was used to analyze nonparametric continuous data. Of the 221 respondents, most identified their programs as based at community (48%) or academic (39%) medical centers. Ninety percent of programs reported inclusion of clinical knowledge and problem-solving assessments in the onsite interview process. The most common assessments included asking clinical questions (70%), development of a SOAP (subjective, objective, assessment, plan) note or care plan (42%), and formal presentations that applicants prepared prior to arrival (39%). Most programs (71%) reported incorporating multiple assessments, with 2 assessments included most commonly (43%). Clinical assessment performance accounted for 10% to 25% of the overall interview score in approximately half of programs. During onsite PGY1 residency interviews, applicants must be prepared to participate in at least 1 clinical knowledge and problem-solving assessment, including answering clinical questions, developing a SOAP note or care plan, and/or delivering a presentation. Applicants should expect that these assessments will account for a substantial portion of the interview evaluation.

Impact of Curricular Integration Between Patient Care Laboratory and Introductory Pharmacy Practice Experience on Documentation

Objective. To assess the impact of curricular changes made through vertical integration between Patient Care Laboratory and Introductory Pharmacy Practice Experience (IPPE) courses on documentation outcomes. Methods. Curricular changes to address student pharmacist documentation deficiencies were developed by laboratory and experiential faculty members. A documentation activity using subjective, objective, assessment, plan (SOAP) notes completed in one IPPE rotation block, pre-intervention, were graded and compared to SOAP notes from the same IPPE rotation block in the subsequent year, post-intervention, using a standard checklist. Chi square test (or Fisher exact test when appropriate) was used to evaluate the relationship between each question's score and different timepoints. Wilcoxon rank sum test was used to compare total scores between the two groups of students. Results. Significant improvement among student pharmacists' SOAP note scores were observed in the post-intervention cohort (n=52) compared to pre-intervention cohort (n=52) following curricular changes. Specific SOAP note components that revealed significant improvements between years were drug therapy problem identified, proposed drug therapy problem resolution, follow-up plan identified, overall impression, and addressing a pharmacist-specific intervention. Conclusion. Collaboration between laboratory and experiential education faculty members are integral to the identification of gaps in student pharmacists' application of simulated activities into actual experiences and in the achievement of educational outcomes. Curricular quality improvements can be implemented and assessed quickly through vertically integrated courses.

Perception of electronic peer review of SOAP notes among pharmacy students enrolling in their first pharmacotherapeutics course

IntroductionThis study aimed to assess the perception of electronic peer review of subjective, objective, assessment, plan (SOAP) notes performed by pharmacy students during their first pharmacotherapeutic course experience. MethodsIn this single-center, cross-sectional study, a questionnaire was administered to students who had undergone an electronic peer review process of a SOAP note. Four areas were assessed: baseline knowledge, development of therapeutic plans, attitudes and perceptions on peer assessment in enhancing SOAP note writing skills, and perceptions of factors that were/would have been helpful toward providing and/or receiving peer assessment. ResultsOne hundred students completed and returned the survey (response rate 61.3%). Most students (93%) reported no prior exposure to writing SOAP notes prior to their participation. SOAP note writing was a valuable component of the module, with most students (97%) recognizing that SOAP note writing skills are important for their future practice as pharmacists. Students also acknowledged that activities in the module improved their abilities to develop (93%) and communicate (80%) patient-specific therapeutic plans in the form of SOAP notes. ConclusionsStudents were comfortable receiving an assessment of a SOAP note from a classmate, and most students indicated that their classmates could provide an honest assessment of their SOAP notes. The electronic peer review process allowed students to receive feedback on their work, and this learning strategy could be further extended to the education of other functional skills that are essential in pharmacy practice.

Assessment of pharmacy students' patient care skills using case scenarios with a SOAP note grading rubric and standardized patient feedback

Background and purposeTo determine if the patient care and documentation skills of pharmacy students improve in the third professional (P3) year using a subjective, objective, assessment, plan (SOAP) note grading rubric and a standardized patient (SP) checklist rubric with SPs taking the role as evaluator during a sequential system of case scenarios. Educational activity and settingDuring a required skills laboratory course in the P3 year at the University of Mississippi School of Pharmacy, students were evaluated with a SOAP note grading rubric and an SP checklist rubric during three consecutive SP case scenarios (hypertension, diabetes, asthma). FindingsOverall, scores for the sequential case scenarios improved across all three scenarios through the use of SOAP notes (F = 96.89, p < 0.0001). For the SP evaluations, total score improved for the second and third case scenarios versus the first (F = 27.48, p < 0.0001). SummaryPatient care skills of P3 pharmacy students improved during a sequential system of case scenarios using a SOAP note grading rubric and an SP checklist rubric as objectively developed evaluation tools, with SPs taking the role as evaluator.

Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE

Objective. To develop and establish validity for a grading rubric to evaluate diabetes subjective, objective, assessment, plan (SOAP) note writing on primary care (PC) advanced pharmacy practice experiences (APPEs), and to assess reliability and student perceptions of the rubric. Methods. Ten PC APPE faculty members collaborated to develop a rubric to provide formative and summative feedback on three written SOAP notes per APPE student over a 10-month period. Correlation analyses were conducted between rubric scores and three criterion variables to assess criterion-related validity: APPE grades, Pharmaceutical Care Ability Profile Scores, and Global Impression Scores. Inter-rater and intra-rater reliability testing were completed using Cohen's kappa and Intraclass Correlation Coefficients (ICC). Student perceptions were assessed through an anonymous student survey. Results. Fifty-one students and 167 SOAP notes were evaluated using the final rubric. The mean score significantly increased from the first to second SOAP note and from the first to third SOAP note. Statistically significant positive correlations were found between final rubric scores and criterion variables. The ICC for inter-rater reliability was fair (.59) for final rubric scores and excellent for intra-rater reliability (.98 to1.00). Students responded that the rubric improved their ability (84.9%) and confidence (92.4%) to write SOAP notes. Conclusion. The rubric may be used to make valid decisions about students' SOAP note writing ability and may increase their confidence in this area. The use of the rubric allows for greater reliability among multiple graders, supporting grading consistency.

Dynamic Electronic Health Record Note Prototype: Seeing More by Showing Less.

Cluttered documentation may contribute adversely to physician readers' cognitive load, inadvertently obscuring high-value information with less valuable information. We test the hypothesis that a novel, collapsible assessment, plan, subjective, objective (APSO) note design would be faster, more accurate, and more satisfying to use than a conventional electronic health record (EHR) subjective, objective, assessment, plan (SOAP) note for finding information needed for ambulatory chronic disease care. We iteratively developed physician clinic note prototypes with features designed to emphasize more important information and de-emphasize less clinically relevant information. Sixteen primary care physicians reviewed comparable clinic notes with the 4 note styles presented in random order to find key information in the notes during timed tasks. The 4 note styles were denoted A (traditional SOAP note), B (2-column APSO note), C (collapsible APSO note), and D (2-column collapsible APSO note). The 4 unique note styles were designed to have equal amounts of information in each section. We simulated their utility for clinical practice by imposing time limits and by interrupting 1 of the tasks with a typical clinical interruption. For each session, we recorded audio, computer-screen activity, eye tracking, and made field notes. We obtained usability ratings (System Usability Scale), new feature preference ratings, and performed semistructured post-task interviews with subsequent content analysis. We compared the effectiveness of the 4 note styles by measuring time on task, task success (accuracy), and effort as measured by NASA Task Load Index. Note styles C and D were significantly faster than A and B for the Review of Systems and Physical Examination tasks, as we expected. Notes B and C had the best success (finding requested data) scores. Users strongly endorsed all the new note features incorporated into the new note prototypes. Previously expressed concerns about temporarily hiding parts of the note (using the accordion display design pattern) were allayed. Usability ratings for note A were worst but comparably better for note styles B, C, and D. The new APSO note prototypes performed better than the traditional SOAP note format for speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Moving Assessment and Plan to the top is 1 easily accomplished feature change. Innovative documentation displays of EHR data can safely improve information display without eliminating data from the record of the visit.

A pilot study on the evaluation of medical student documentation: assessment of SOAP notes.

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.

Assessment of a Revised Method for Evaluating Peer-graded Assignments in a Skills-based Course Sequence

OBJECTIVE. To evaluate the modified peer-grading process incorporated into the SOAP (subjective, objective, assessment, plan) note sessions in a skills-based pharmacy course sequence. DESIGN. Students assessed a de-identified peer's SOAP note in a faculty-led peer-grading session followed by an optional grade challenge opportunity. Using paired t tests, final session grades (peer-graded with challenge opportunity) were compared with the retrospective faculty-assigned grades. Additionally, students responded to a survey using 4-point Likert scale and open-answer items to assess their perceptions of the process. ASSESSMENT. No significant difference was found between mean scores assigned by faculty members vs those made by student peers after participation in 3 SOAP note sessions, which included a SOAP note-writing workshop, a peer-grading workshop, and a grade challenge opportunity. The survey data indicated that students generally were satisfied with the process. CONCLUSION. This study provides insight into the peer-grading process used to evaluate SOAP notes. The findings support the continued use of this assessment format in a skills-based course.

Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record.

Larry Weed, MD is widely known as the father of the problem-oriented medical record and inventor of the now-ubiquitous SOAP (subjective/objective/assessment/plan) note, for developing an electronic health record system (Problem-Oriented Medical Information System, PROMIS), and for founding a company (since acquired), which developed problem-knowledge couplers. However, Dr Weed's vision for medicine goes far beyond software--over the course of his storied career, he has relentlessly sought to bring the scientific method to medical practice and, where necessary, to point out shortcomings in the system and advocate for change. In this oral history, Dr Weed describes, in his own words, the arcs of his long career and the work that remains to be done.

Are Electronic Health Records Good for Health Care?

Are Electronic Health Records Good for Health Care?

The Systems SOAP Note: A Systems Learning Tool.

Systems-based practice (SBP) is the only Accreditation Council for Graduate Medical Education (ACGME) competency concerned with public health and is relatively neglected in residency curricula. A tool was developed and pilot-tested to improve SBP learning on inpatient psychiatry rotations. A four-step approach was used: (1) literature review, (2) expert consultation, (3) tool development, and (4) pilot testing on four cases and evaluation for completion time and preliminary efficacy. Out of 51 SBP articles, six (12%) focused on psychiatric residency programs, and none had a practical SBP learning tool. The "systems SOAP (subjective, objective, assessment, plan) note" (S-SOAP) was structured after a clinical SOAP note and was easy to use (mean completion time = 60 min), and residents self-reported more insight into systems issues. The S-SOAP tool was effectively integrated into clinical experience and provided insight into systemic complexities. Future research should assess SBP knowledge acquisition after the use of such tools.

Evaluation of peer-graded assignments in a skills-based course sequence

Peer grading has been used in higher education to assist in the evaluation process and enhance student learning. One form of active learning relevant to pharmacy practice is written documentation using the subjective, objective, assessment, plan (SOAP) format. The purpose of this study was to evaluate the peer-grading process utilized for three SOAP note assignments for pharmacy students enrolled in a skills-based course sequence entitled Professional Skills Development (PSD). Objectivewere to compare student and faculty scores for assignments and gather the students' perceptions about the peer grading sessions. To each SOAP note was graded by a blinded peer in a class session and graded independently by the faculty instructor. A survey was given to the students after the third SOAP note session to assess their perceptions of the grading sessions. ResultsFor each of the sessions, the peer SOAP note score was lower than the faculty score (p<0.001). Seventy-nine percent of the students (n = 98) completed the survey. The majority strongly agreed or agreed that the instructions were clear, the checklists were easy to follow, their learning was enhanced, faculty guidance allowed them to effectively grade a peer's SOAP note, and peer grading should be used more frequently in the curriculum. ConclusionPeer grading is useful in evaluating student SOAP note assignments and perceived by students as a valuable learning exercise.

Using Electronic Medical Records to Teach Patient-Centered Care

To develop, implement, and evaluate the use of electronic medical records (EMRs) in disease state management activities to teach pharmacy students patient-centered care skills. Faculty created 12 patient cases and an EMR for each simulated patient. Students used the information in the EMR to confirm the presence of a disease in their patient; to design and monitor an evidence-based patient-centered care plan, and document their assessment, medication, and monitoring recommendations; and to follow up in a SOAP (subjective, objective, assessment, plan) note format within the EMR. A precourse and postcourse survey instrument was administered to assess students' perceived gains in knowledge and attitudes regarding the use of EMRs for learning patient-centered care skills. A grading rubric was used to evaluate each SOAP note. Implementation of disease state management activities involving EMRs improved pharmacy students' patient care skills.

A repurposed tool: the Programme Evaluation SOAP Note

Doctors have used the subjective-objective-assessment-plan (SOAP) note format to organise data about patient problems and create plans to address each of them. We retooled this into the 'Programme Evaluation SOAP Note', which serves to broaden the clinician faculty member's perspective on programme evaluation to include the curriculum and the system, as well as students. The SOAP Note was chosen as the method for data recording because of its familiarity to clinician-educators and its strengths as a representation of a clinical problem-solving process with elements analogous to educational programme evaluation. We pilot-tested the Programme Evaluation SOAP Note to organise faculty members' interpretations of integrated student performances during the Year 3 patient care skills objective structured clinical examination (OSCE). Eight community clerkship directors and lead clerkship faculty members participated as observers in the 2007 gateway examination and completed the Programme Evaluation SOAP Note. Problems with the curriculum and system far outnumbered problems identified with students. Using the Programme Evaluation SOAP Note, clerkship leaders developed expanded lists of 'differential diagnoses' that could explain possible learner performance inadequacies in terms of system, curriculum and learner problems. This has informed programme improvement efforts currently underway. We plan to continue using the Programme Evaluation SOAP Note for ongoing programme improvement.

Patient Note Fabrication and Consequences of Unprofessional Behavior in a High-Stakes Clinical Skills Licensing Examination

The National Board of Osteopathic Medical Examiners (NBOME) administers the Comprehensive Osteopathic Medical Licensing Examination USA Level 2-PE (COMLEX-USA Level 2-PE) and has developed a process that links the competencies of written communication and professionalism by tracking fabrication in the postencounter SOAP (Subjective, Objective, Assessment, Plan) note exercise. A process used to identify potential SOAP note fabrication was implemented in the 2007-2008 test cycle for the COMLEX-USA Level 2-PE. A total of 3,753 candidates took the COMLEX-USA Level 2-PE in the 2007-2008 test cycle. Forty-eight candidates were screened, and the NBOME's Subcommittee on SOAP Note Fabrication made failure decisions on eight, leading to a failure rate of 0.2% based on fabrication review. The NBOME has adopted the stance that postencounter note fabrication represents unprofessional behavior. Screening for and failing candidates who exhibit unprofessional behavior enhances the validity of the examination.