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Progress, Medical interns, Training, IntroductionMedical records have various uses such as follow-up care, training, research, communicating with the staff involved in health care, providing information to organizations, planning health services, improving quality of health service, supporting the patients, supporting healthcare providers, as well as evaluating the health service delivery ( 1,). Medical records can help healthcare providers in planning and evaluating the patients&,rsquo treatment process and ensuring the continuity and quality of patient&,rsquo s care by different healthcare providers. Medical records document the patient&apos,s condition, length of stay, examinations, treatments, clinical progress, and interactions between patient and healthcare providers during a course of treatment ( 2,).One of the most important documents in medical records is the daily progress note, which presents the patient&,rsquo s latest information and daily clinical progress as well as summarizing the ongoing evaluation done by the healthcare provider team and their plan and schedule for the patient. The daily progress notes should reflect what has been diagnosed over the past 24 hours and include new patient-reported content, new points obtained from inpatient examination and paraclinical investigations, as well as differential diagnosis and planning used to write daily progress notes in the Subjective, Objective, Assessment, and Plan (SOAP) note format. The SOAP note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a means for healthcare providers to document in a structured and organized way ( 3,). There is a close relationship between the clinical progress of an illness and the physician&apos,s daily orders. Thus, recording the progress of an illness along with the orders issued by the physician based on the SOAP model can increase the level of information in the records that leads to correct diagnostic and therapeutic order and enhances the educational quality of the learners. Given the need for standard documentation, health care providers need to know the correct standardized process of medical recording. Previous research reports that healthcare providers have performed poorly in completing the progress note ( 4,). The results of numerous studies also demonstrate that some factors such as knowledge, attitude, training, guidelines, standards, and supervision can influence the quality of documentation and progress note writing ( 5,). It is mentioned that one of the most useful ways to improve the quality of documents is to train medical staff to follow the principles of documentation ( 6,, 7,). Appropriate clinical training methods are needed to develop appropriate skills and knowledge in medical interns. Writing a progress note is a common and important component of the medical education curriculum in most countries, and its evaluation and standardization can improve the quality of medical education ( 8,, 9,). The progress note can be offered as an important tool to reduce medical errors and improve overall standards of patient care.The Ministry of Health of Iran has designed and conducted a national project on clinical education criteria and indicators in training medical universities and hospitals to present a set of clinical education standards. This project resulted in the introduction of medical clinical education standards for outpatient clinics, educational rounds, grand rounds, morning reports, and journal club, and was announced in the fall of 2009. Unfortunately, despite the great importance of daily attention to the patients&,rsquo condition, clinical examinations, laboratory test results and imaging in the diagnosis and planning treatment for patients and the necessity of writing them in medical records, there is no formal educational or training course about progress note writing in Iranian medical interns&apos, curriculum ( 10,).In other countries, due to the diversity of experience and training among health care providers, a standard progress note form has been developed to create consistency and assure a certain level of quality in the daily progress note writing and has been revised in recent years. This form enables the user to have the basic necessary information to evaluate the patient accurately and adequately. The progress note can also serve as an outcome-based learning experience for structural evaluation and assessment of the trainee&,rsquo s progress ( 8,, 11,).In Iran&apos,s hospitals, in a medical record, especially in progress note writing, there are many defects and shortcomings. The findings of a study in Iran showed that assistants and interns had a moderate performance in medical recording ( 5,). It is expected that after completing a training course and acquiring scientific and clinical skills, medical interns will be experts in writing medical reports and progress notes ( 7,).Due to the flaws in the writing of daily progress notes in medical records and to improve the medical interns&,rsquo ability to write a progress note, the present study aimed to survey the effectiveness of a training intervention designed to improve Iranian medical interns&apos, progress note writing skills.MethodsStudy SettingThis quasi-experimental study (pre- and post-test) was conducted over an 8-month period in the internal medicine ward at Razi Hospital of Rasht (affiliated to Guilan University of Medical Sciences), northern Iran. Population and SamplingThe participants consisted of all general medical interns (n=150) at Razi Hospital that were enrolled during Oct.2018-May.2019. The sampling method was the census. The age and gender of all interns were recorded.Inclusion and Exclusion CriteriaAll Iranian medical interns (male and female) at Razi Hospital who were in the 4th year of medical courses or higher and had experience in the clinical unit were included. These interns did not go through any educational course for daily progress note writing. Exclusion criterion was lack of willingness to participate in the study.ProcedureIn the baseline, daily progress notes written by 150 medical interns were assessed by the expert panel using a SOAP-based questionnaire. The score was recorded. Then, in the intervention phase, training sessions (4 one-hour sessions) on how to write the daily progress note based on SOAP format in the patient&apos,s medical records were held for all 150 medical interns.After the training intervention, medical interns were given a week to meet the SOAP standards. Then, the same expert panel reviewed and assessed the newly written daily progress notes of the same medical interns for a period of 20 days (150 cases) and the scores were recorded. Finally, the scores obtained from the evaluation of progress note writing based on SOAP, before and after the intervention, were compared.Expert PanelThe expert panel included 4 internal medicine specialists and 1 biostatistician. Training InterventionTraining sessions (4 one-hour sessions) on how to write daily progress note based on SOAP were held for 2 weeks for 150 medical interns. In these training sessions, the importance, necessity and application of daily progress note writing were presented to interns by the expert panel. All medical interns received were taught about the &,ldquo best practices&,rdquo and instructions about the use of the SOAP note. The detected defects in daily progress notes written by medical interns in baseline were identified based on SOAP. Then, training sessions were continued using the problem-solving method, emphasizing the necessity of adhering to the standard and correct recording based on the SOAP note. At the same time, the content was presented with slides, and defects in the written daily progress report were corrected by the interns under the guidance of the expert panel. Finally, the expert panel answered some questions from medical interns in their progress note writing.It is noticeable that after holding training sessions and scoring all medical interns after training, one workshop was conducted to detect their errors and gaps in progress note writing after 4 training sessions.SOAP-based QuestionnaireThe data collection tool was a questionnaire based on the SOAP guidelines for writing progress notes according to the Ministry of Health of Iran (Table 1,) ( 12,). This questionnaire contained 47 questions in 5 components General rule (n=7), Subjective (n=7), Objective (n=11), Assessment (n=14), and Plan (n=8). A five-point&,nbsp Likert scale&,nbsp was used for scoring (very good=5, good=4, average=3, poor=2, very poor=1, none/Blank=0). The score of each component is converted linearly to a scale of 0-100 points, with 100 representing the best score and zero denoting the worst score.General rule 1The date of all notes is written.2The time (clock) of all notes is written.3The position of the note recorder is mentioned.4All notes are legible.5The note recorder Seal and Signature is available (for all notes).6The note adheres to the general principles of SOAP.7All of the notes areproblem oriented in general.Subjective 1The patient&apos,s description of his/her complaint is recorded.2The date of the commencement of his/her complaint is recorded.3If the patient cannot speak, attention is given to nonverbal communication.4The patient&apos,s previous performance is recorded according to his/her opinion.5The patient&,rsquo s expectation of the treatment is considered as a goal. 6Is the problem recorded by the patient him/herself?7The patient&apos,s new problem intervals have been recorded.Objective 1The results of the physical examination are recorded.2Onset of abilities or improvements is recorded in the examination.3Onset of disabilities or impairments is recorded in the examination.4Is the conducted intervention recorded?5If done, is the time of intervention recorded?6If done, is the location of intervention recorded?7If done, is the duration of intervention recorded?8If done, is the type of intervention recorded?9Are the results of laboratory test recorded?10Are the results of the graphs recorded?11Are vital signs recorded?Assessment 1Does the Professional Assessment combine the objective + assessment components?2It identifies the onset of the problem or limitation.3Listing of the problems is accessible.4Prioritization of the problems is accessible.5The factors causing this problem are recorded.6Patient&,rsquo s response to the intervention (improvement/ unchanged/ worsening) is recorded.7An emotional response to treatment is recorded.8The rehabilitation prognosis (excellent / good / poor / for recovery) is recorded.9The necessity for continued treatment is written.10&,ldquo No transcription (copy/paste) of laboratory test&,rdquo is performed.11A differential diagnosis or a definitive diagnosis of the problem is made. 12The severity of the problem is recorded.13Problem status is recorded (for better or worse).14The assessment change is recorded compared to the previous day.Plan 1Orders have been raised about whether to continue treatment or change treatment plan.2A distinction between short- and long-term goals has been mentioned.3Summarizing for both short- and long-term goals is done.4The goals are recorded in a specified time frame.5Estimates about the likely length of time required for a complete treatment plan are given. 6A patient or family training program is outlined.7Follow up is provided.8Other expert advice is available.SOAP, Subjective, Objective, Assessment, and Plan |
| نویسندگان مقاله |
IRANDOKHT SHENAVAR MASOOLEH |
Medical Education Research Center, Educational Development Center, Guilan University of Medical Sciences, Rasht, Iran
ELHAM RAMEZANZADEH |
Razi Clinical Research Development Centre, Guilan University of Medical Sciences, Rasht, Iran
MARYAM YASERI |
Razi Clinical Research Development Centre, Guilan University of Medical Sciences, Rasht, Iran
SEYYEDE SAHERE MORTAZAVI KHATIBANI |
Gastrointestinal and Liver Diseases
Research Center, Guilan University of Medical Sciences, Rasht, Iran
HANIEH SADAT FAYAZI |
Razi Clinical Research Development Centre, Guilan University of Medical Sciences, Rasht, Iran
HEYDAR ALI BALOU |
Medical Education Research Center, Educational Development Center, Guilan University of Medical Sciences, Rasht, Iran;
HOURVASH EBRAHIMI LOUYEH |
Medical Education Research Center, Educational Development Center, Guilan University of Medical Sciences, Rasht, Iran
FATEMEH ZAERSABET |
Medical Education Research Center, Educational Development Center, Guilan University of Medical Sciences, Rasht, Iran
HOSSEIN KHOSHRANG |
Medical Education Research Center, Educational Development Center, Guilan University of Medical Sciences, Rasht, Iran;
IDEH DADGARAN |
Medical Education Research Center, Educational Development Center, Guilan University of Medical Sciences, Rasht, Iran
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