加强内部医学中的SOAP文档:索巴大学医院的三周期临床审计
Maisaa Mohamed1, Mohja Yosif2, Latifa Mohamed1
1Internal Medicine, Soba University Hospital, Khartoum, SDN.
Cureus
|December 24, 2025
概括
改善苏丹的临床文档对于患者安全至关重要. 有针对性的干预措施提高了SOAP笔记的质量,特别是主观和计划部分,尽管需要进一步研究行政和客观数据.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 临床文档标准 临床文档标准
- 医疗记录 保持医疗记录
背景情况:
- 高质量的临床文档,特别是SOAP (主观,目标,评估,计划) 格式,对于患者安全和医疗保健至关重要.
- 在苏丹,不良的文档记录与护理连续性问题和医疗错误有关.
研究的目的:
- 为了评估和提高SOAP文档的质量在Soba大学医院的内部医学系,喀土穆.
- 实施和评估有针对性的干预措施对记录实践的影响.
主要方法:
- 对111名患者记录 (2021年3月至2022年3月) 进行了回顾性,三周期的临床审计.
- 使用了一个本地适应的SOAP检查列表,包含21个标准.
- 实施的干预措施包括教育,指导,模板和设备改进.
主要成果:
- 最初的审计显示出重大缺陷;只有两个标准符合≥80%的合规标准.
- 干预后,社会史记录改善了48.4%,病史改善了25.7%,药物规划达到了80%的遵守.
- 在行政数据,客观组件和过敏文档方面存在差距;差异诊断文档各不相同.
结论:
- 有针对性的干预措施显著提高了SOAP文档质量,特别是主观和计划组件.
- 行政和客观文档标准需要进一步改进.
- 持续的教育,标准化的流程和系统性改革是苏丹医疗保健更广泛的质量改善所必需的.
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