提高后续文档的质量使用结构化的主观,目标,评估和基于计划 (SOAP) 的模板:苏丹哈萨赫萨教学医院的两周期临床审计
Maram Hassan Ali Mohamed1, Mohamed Hassan Ali Mohamed2, Amro Osama Fathi Mohammed3
1Department of Neonatology, Maternity and Children's Hospital - Najran, Najran, SAU.
Cureus
|January 28, 2026
概括
实施标准化的主观,目标,评估和计划 (SOAP) 模板,并进行培训,在资源有限的医院显著提高了临床随访文档质量. 这提高了医疗记录的保存和患者护理的连续性.
科学领域:
- 临床医学 临床医学
- 改善医疗保健质量 改善医疗保健质量
- 医疗文件 医疗文件
背景情况:
- 在资源有限的纸质环境中,不完整和不结构化的后续笔记阻碍了临床决策,护理连续性和患者安全.
- 沟通缺口和低于最佳的护理是糟糕的文档实践的常见后果.
研究的目的:
- 评估标准化主观,目标,评估和计划 (SOAP) 模板和员工培训对后续说明的完整性和组织性的影响.
- 评估结构化文档在资源有限的医院环境中的可行性和有效性.
主要方法:
- 在Hasahesa教学医院六个月内进行了前性,两周期的临床审计.
- 一个多方面的干预包括一个标准化的SOAP模板,员工教育和强化.
- 随访笔记在干预前和干预后使用结构化的形式进行评估,并通过描述性和千平方测试分析数据.
主要成果:
- 在干预后,在所有SOAP领域都观察到显著的改善.
- 主观,客观,评估和计划要素的完整性和组织性大大提高.
- 对SOAP结构的总体遵守率大幅上升,这表明文档质量有所提高.
结论:
- 一个基于SOAP的结构化模板,在有针对性的培训的支持下,在资源有限的纸质环境中,有效地改进了后续文档.
- 该干预措施证明了其实用性和高效性,提高了文档质量.
- 持续改进需要持续的教育,重新审计和整合到部门实践中.
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