بررسی تاثیر آموزش تلفیقی روش SOAP استاندارد بر ثبت صحیح سیر بیماری در پرونده ی پزشکی بیماران توسط دستیاران تخصصی جراحی عمومی

Background & Objectives: Medical records are among the most valuable tools for the evaluation of service quality of care organizations. Generally, a course disease shows the latest daily status of patients. This research aimed to determine the effect of blended learning (standard SOAP method) on the accurate progress note documentation in medical records of patients by assistants of general surgery. Materials and Methods: This quasi-experimental research was performed with the cooperation of 10 first to fourth-year assistants of general surgery in Shahid Modarres Hospital affiliated with Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2016. Samples included medical records of patients selected by randomized sampling. In total, 412 medical records were evaluated before the intervention in terms of progress note documentation using a questionnaire designed based on medical documentation standard (progress note based on the SOAP) of the ministry of health, treatment, and medical education. In addition, 420 medical records were assessed after the intervention, which included education of standard notes on accurate progress note documentation based on SOAP through peer-to-peer problem solving and using emails (blended learning). Data analysis was performed in SPSS version 18.5 using paired t-test and McNemar test for quantitative and qualitative binary nominal variables, respectively. Results: In this research, a significant difference was observed before and after education based on the standard SOAP in terms of progress note documentation of patients upon admission, during treatment and at discharge (P=0.005). Moreover, a significant difference was found between the condition of information documentation related to the physician (patient’s name, the sequence of progress note report, and time) before and after the education (P=0.005). Conclusion: According to the results of the present study, documentation of the general status, care and diagnostic measures, treatment plan and observing the standard principles in the progress note sheet of patients by the assistants of general surgery were improved after blended learning.