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

Ji-Hyun SeoHyun-Hee KongSun-Ju ImHyerin RohDo-Kyong KimHwa-Ok BaeYoung-Rim Oh
Published in: Korean journal of medical education (2016)
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.
Keyphrases
  • medical students
  • mental health
  • healthcare
  • electronic health record
  • quality improvement
  • high resolution
  • physical activity
  • advance care planning
  • genome wide
  • dna methylation