INNOVATIONS in pharmacy

Development and Evaluation of Students’ Skills Critiquing Clinical Documentation

Kassandra M Bartelme

Michael C Brown

DOI: https://doi.org/10.24926/iip.v7i1.422

Keywords: SOAP, documentation, teaching laboratory

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Abstract

Objectives: The main objective is to evaluate students’ ability to critique simulated clinical documentation containing intentional errors. Exploratory objectives include comparing student performance on two note critique activities and comparing performance of two consecutive student cohorts.

Methods: Students are introduced to the skills of clinical documentation in the second professional year. To uniquely develop students’ ability to identify challenges that may be present with notes in their future practice, students were taught specific skills in critiquing documentation, with an emphasis on the errors and omissions commonly seen in different sections of the note based on the previous literature. Students were assessed on their ability to correctly critique two notes containing intentional errors in two teaching laboratory courses.

Results: A total of 159 students completed two note critique activities, identifying 87.0% of intentional errors built into both activities. On the individual note components, students identified 97.9%, 73.0%, 78.8%, and 95.5% of the intentional errors in the subjective, objective, assessment, and plan (SOAP) sections, respectively.

Conclusion: Students perform fairly well when identifying errors in poorly written SOAP notes. They seem to struggle most with identifying intentional errors in the objective and assessment sections. Future instructional efforts will target improving students’ abilities critiquing these sections.

 

Type: Original Research