title: A pilot study on the evaluation of medical student documentation: assessment of SOAP notes.
abstract: The purpose of this study was evaluation of the current status of medical students' documentation of patient medical records.
  
  
  
  We checked the completeness, appropriateness, and accuracy of 95 Subjective-Objective-Assessment-Plan (SOAP) notes documented by third-year medical students who participated in clinical skill tests on December 1, 2014. Students were required to complete the SOAP note within 15 minutes of an standard patient (SP)-encounter with a SP complaining rhinorrhea and warring about meningitis.
  
  
  
  Of the 95 SOAP notes reviewed, 36.8% were not signed. Only 27.4% documented the patient's symptoms under the Objective component, although all students completed the Subjective notes appropriately. A possible diagnosis was assessed by 94.7% students. Plans were described in 94.7% of the SOAP notes. Over half the students planned workups (56.7%) for diagnosis and treatment (52.6%). Accurate documentation of the symptoms, physical findings, diagnoses, and plans were provided in 78.9%, 9.5%, 62.1%, and 38.0% notes, respectively.
  
  
  
  Our results showed that third-year medical students' SOAP notes were not complete, appropriate, or accurate. The most significant problems with completeness were the omission of students' signatures, and inappropriate documentation of the physical examinations conducted. An education and assessment program for complete and accurate medical recording has to be developed.
authors.affiliation: Department of Pediatrics, Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea.
authors.forename: Ji-Hyun
authors.identifier: 0000-0002-0691-3957
authors.initials: JH
authors.lastname: Seo
authors.affiliation: Department of Parasitology, Dong-A University College of Medicine, Busan, Korea.
authors.forename: Hyun-Hee
authors.identifier: 0000-0003-1075-0051
authors.initials: HH
authors.lastname: Kong
authors.affiliation: Medical Education Unit, Pusan National University School of Medicine, Busan, Korea.
authors.forename: Sun-Ju
authors.identifier: 0000-0002-3038-3570
authors.initials: SJ
authors.lastname: Im
authors.affiliation: Department of Medical Education, Inje University College of Medicine, Busan, Korea.
authors.forename: HyeRin
authors.identifier: 0000-0002-3879-709X
authors.initials: H
authors.lastname: Roh
authors.affiliation: Department of Medical Humanities, Dong-A University College of Medicine, Busan, Korea.
authors.forename: Do-Kyong
authors.identifier: 0000-0001-8639-1951
authors.initials: DK
authors.lastname: Kim
authors.affiliation: Department of Social Welfare, Gyeongsang National University, Jinju, Korea.
authors.forename: Hwa-Ok
authors.identifier: 0000-0002-3962-6911
authors.initials: HO
authors.lastname: Bae
authors.affiliation: Department of Obstetrics & Gynecology, Kosin University College of Medicine, Busan, Korea.
authors.forename: Young-Rim
authors.identifier: 0000-0002-0376-1345
authors.initials: YR
authors.lastname: Oh
mesh_terms: D002982:Clinical Clerkship; D002983:Clinical Competence / Q000592:standards*; D004282:Documentation / Q000592:standards*; D004504:Education, Medical, Undergraduate; D004521:Educational Measurement; D006801:Humans; D008499:Medical Records; D010808:Physical Examination; D010865:Pilot Projects; D056910:Republic of Korea; D013337:Students, Medical; D014495:Universities
keywords: Documentation; Medical records; Medical students