SOAP Note written documentation needs assessment and course methodology evaluation for on-line course

Purpose: The objective of this study was to 1) evaluate practicing pharmacist’s experiences with clinical documentation experiences and 2) evaluate the effectiveness of an online clinical documentation educational intervention.

Methods: As part of an online course for first year licensed pharmacists enrolled in an online PharmD degree program, 93 individuals completed a pre-survey exploring demographics and experiences with clinical documentation and evaluated a SOAP note. Over the course of three weeks, individuals participated in didactic learning modules related to clinical documentation and note writing and completed practice exercises and a comprehensive self-assessment. Following the completion of the learning activities, individuals complete a post-assessment and evaluated a SOAP note.

Results:  1. 49% of the 93 participants stated no prior instruction related to the documentation of patient care. Among those that reported previous instruction, 50.5% indicated that they received on-the-job training, 16.5% stated they received training during intern or externship, 15.5% reported a combination of intern / externship and job training, and 17.5% reported that they were self-learned. 2. Post-survey results indicated on average 50% learners were able to identify 50% of the necessary components for subjective and objective information, 42% for assessment, 88% for recommendation, and 83% for monitoring plan. 3. 82% used self-assessment activities to guide their learning. 22% of participants used that self-assessment once, 54% of participants made two to three attempts at the self-assessment activity, and 10.5% made four or more attempts (attempt range 1-9). 4. All post-survey respondents stated the combinations of lecture examples; self-assessment, grading note exercise, and the rubric were useful for learning and practicing written documentation. 5. Student’s ability to grade and assess the appropriateness of notes, evaluated pre and post completion of learning activities, improved. Students still struggle with creating assessments.

Conclusion: On-line methods can be effective for assessing and teaching basic clinical documentation skills and guiding future learning strategies.