SOAP Methodology in General Practice/Family Medicine Teaching in Practical Context

Area of Science:

• Medical Education
• Family Medicine
• Clinical Documentation

Background:

• Medical records are crucial for patient health status and professional communication in General Practice/Family Medicine.
• Developing medical record-keeping skills is essential for pre-graduating medical students.
• The Subjective, Objective, Assessment and Plan (SOAP) methodology has been used since 2012 for student evaluations.

Purpose of the Study:

• To evaluate medical student performance using the SOAP methodology during clinical visits.
• To identify specific areas within the SOAP framework where students face the most difficulties.
• To correlate student performance with patient evaluations and tutor feedback.

Main Methods:

• Analysis of evaluation data from fourth-year medical students during General Practice/Family Medicine visits (2015-2016).
• Comparison of average scores for each component of the SOAP checklist.
• Assessment of patient evaluations alongside tutor feedback.

Main Results:

• 29.7% of students achieved the best grade quartile, 37.1% the best competencies quartile, and 27.2% the best patient grade quartile.
• Lowest scores were observed in 'Evolution was verified/noted' (Subjective), 'Record of physical examination focused on the problem' (Objective), 'Notes of Diagnostic reasoning / differential diagnostic' (Assessment), and 'Negotiation of aims to achieve' (Plan).
• Tutors provided the highest evaluation for 'communication' skills.

Conclusions:

• Students demonstrate good overall performance in applying the SOAP method.
• The study highlights specific areas within the SOAP methodology that require targeted teaching interventions.
• This evaluation provides a foundation for developing improved methods to teach challenging aspects of clinical documentation.