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

作　　者：吴至凤 明黎 杨张娅 王敏 孙艺珍 杨望 陈志强 胡章雪 张雨平 Wu Zhifeng;Ming Li;Yang Zhangya;Wang Min;Sun Yizhen;Yang Wang;Chen Zhiqiang;Hu Zhangxue;Zhang Yuping(Department of Pediatrics,The Second Affiliated Hospital of Army Medical University,Chongqing 400037,China;Department of Pediatrics,The First Affiliated Hospital of Army Medical University,Chongqing 400038,China;Department of Pediatrics,Army Characteristic Medical Center of PLA,Chongqing 400042,China)

机构地区：[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

出　　处：《中华医学教育探索杂志》2024年第7期906-909,共4页Chinese Journal of Medical Education Research

基　　金：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。

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。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 

分 类 号：R-05[医药卫生]