Validation of computer-mediated open-ended standardized patient assessments

Heun, Linda; Brandau, D; Chi, Xuming; Ping, Wang; Kangas, Jeanne

doi:10.1016/s1386-5056(98)00074-4

Cited by 4 publications

(8 citation statements)

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“…[ 12 ] This also promotes the exploration of drug interaction cases and facilitates easy reporting. One of the burning examples was set by old research by Heun et al, [ 2 ] who reported the performance of the SOAP Note Plus program (a computer-based SOAP-integration approach) at Kirksville College of Osteopathic Medicine in 1995. The program helped modify the closed-ended assessment into an open-ended one to address the broad range of clinical problems, promote standardized patient assessment, and automate the postvisit evaluation and documentation.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…The program helped modify the closed-ended assessment into an open-ended one to address the broad range of clinical problems, promote standardized patient assessment, and automate the postvisit evaluation and documentation. [2] Disease ICD classification [24] Frequency (%) for Mortality and Morbidity Statistics (Version: 09/2020). [24] BPH = benign prostatic hyperplasia; COPD = chronic obstructive pulmonary disease; DM-II = type II diabetes mellitus; HTN = hypertension; URTI = upper respiratory tract infection; UTI = urinary tract infection.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7] These notes help in patients' chronological clinical evaluation with the comprehensive analysis of their health problems and formulate treatment plans accordingly. [2,3,[6][7][8] Although it is a structured note, there is no single definitive format for SOAP documentation as health professionals across diverse health care settings may differently maintain SOAP documentation. [9] However, the widely adopted format is subjective (S), objective (O), assessment (A), and plan (P), where the subjective data are disease/symptoms-related information or chief complaints obtained from the patients and/or their caretakers, and the objective data are taken from observation, physical examination, and diagnostic studies (such as clinical laboratory and radiologic investigations).…”

Section: Introductionmentioning

confidence: 99%

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Community pharmacy-based SOAP notes documentation

Sapkota

Shrestha²,

Giri³

2022

Medicine

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There is still scarce and sparse evidence regarding documentation of the subjective, objective, assessment and plan (SOAP) note in community pharmacies despite its long implementation history in clinical and academia settings. Hence, we aimed to document and maintain SOAP notes for individual patients visiting community pharmacies for their health problems.We conducted a community-based cross-sectional study at 2 community pharmacies in Nepal from July to December 2019. We recruited 400 patients from all age groups suffering from any health problem using simple random sampling. Patients' subjective complaints were retrieved from their respective prescriptions and verified by interviewing them. Data were collected on the standard format of the SOAP notes and all data related to patients' subjective and objective evaluations, and assessments and plans were descriptively analyzed with R programming 4.0.3. Drug interaction profile was checked with the Medscape Drug Interaction Checker.A total of 87 (21.8%) patients aged 42 to 51 years participated in the research, out of whom 235 (58.8%) were female, 208 (52%) illiterate, 359 (89.8%) were facing mild polypharmacy, and 40 (9.9%) were suffering from joint, leg, ankle, and knee pain. There were 41 minor (11.4%), 130 major (32.7%), and 3 severe (0.9%) drug interaction cases (i.e., medication-related problems), with 11 (2.8%) occurring between amlodipine and metformin, which required close monitoring. There were 226 (56.5%) cases with follow-up planned for the patients when necessary.This novel approach in documenting SOAP notes at community pharmacies during dispensing would be an extended form of the same being applied in clinical settings. Hence, this would open a new arena for the community pharmacists to expand their professionalism beyond the clinical and academia by documenting patients' complex disease and medication profiles in their documentation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Community pharmacy-based SOAP notes documentation

Sapkota

Shrestha²,

Giri³

2022

Medicine

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“…Implementation of electronic entry in medical documentation, both in clinical and educational settings, has posed some concerns. 2,[4][5][6][7][8][9] Are students and residents comfortable with typing? Will keyboard data entry affect the degree to which students and residents are permitted to record a patient encounter in a clinical setting?…”

Section: Discussionmentioning

confidence: 99%