摘要：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.
关键词：Medical records;Documentation;Medical students
