基于SOAP的临床见习日志设计及应用
Design and application of clinical probation log based on subjective-objective-assessment-plan
吴至凤 1明黎 1杨张娅 1王敏 1孙艺珍 1杨望 1陈志强 2胡章雪 3张雨平1
作者信息
- 1. 陆军军医大学第二附属医院儿科,重庆 400037
- 2. 陆军军医大学第一附属医院儿科,重庆 400038
- 3. 陆军特色医学中心儿科,重庆 400042
- 折叠
摘要
目的 设计基于SOAP[subjective(主观资料),objective(客观资料),assessment(评估),plan(计划)]的新版临床见习日志并验证其使用效果.方法 在秋季学期见习的97名学生中,通过定量与定性研究评估基于SOAP结构化病历的新版日志对学生见习成绩及临床思维的影响.定量指标采用SPSS 26.0软件行t检验和方差分析.结果 新版见习成绩[(96.29±1.38)分]较旧版[(93.53±1.60)分]好,差异有统计学意义(P<0.001);进一步行多因素分析显示先使用旧版后使用新版的学生成绩提升显著优于先使用新版后使用旧版的学生(P<0.001).定性访谈显示手写见习日志非常有必要,新版较旧版更能促进学员临床思维有序化,教员点评环节可提供反馈,所有受访学生均表示新版日志值得推广.结论 引入SOAP结构化病历的新版临床见习日志有助于提升见习效果,培养学生有序化的临床思维能力,值得在见习教学中推广.
Abstract
Objective To investigate the application value of a new clinical probation log designed based on the subjective-objective-assessment-plan(SOAP)structured medical record.Methods Quantitative and qualitative studies were conducted among 97 students in the autumn semester to evaluate the effect of the new clinical probation log based on the SOAP structured medical record on their academic performance and clinical thinking.SPSS 26.0 was used to perform the t-test and ANOVA.Results The students using the new version had a significantly better score(96.29±1.38)than those using the old version(93.53±1.60)(P<0.001),while the multivariate analysis showed that the students who first used the old version and then switched to the new version had a significantly better improvement in the score compared with those who first used the new version and then switched to the old version(P<0.001).The qualitative interview showed that it was necessary to use handwritten internship log,and compared with the old version,the new version could better promote the ordered clinical thinking of students.The teacher comments could give feedbacks,and all the students interviewed thought that the new version held promise for clinical application.Conclusions The clinical probation log based on the SOAP structured medical record can help to improve the effectiveness of probation and cultivate clinical thinking ability,and thus it holds promise for application in clinical probation teaching.
关键词
见习教学/日志/SOAP临床思维模式/反馈教学/医学生Key words
Probation teaching/Probation log/Subjective-objective-assessment-plan clinical thinking pattern/Feedback teaching/Medical student引用本文复制引用
基金项目
陆军军医大学教育改革重点课题(2021A09)
陆军军医大学信息化教学课题(2021A09)
出版年
2024
NETL
NSTL
万方数据