Integration of an Internet-based Medical Chart Into a Pharmacotherapy Lecture Series

Abstract

Objectives. To integrate an Internet-based medical chart (IMC) system into a pharmacotherapy course to facilitate evaluation and feedback processes, foster development of written documentation skills, and prepare pharmacy students for future changes in electronic medical documentation systems.Design. An IMC system was introduced into a pharmacotherapy course for third-professional year pharmacy students and 4 ''finish the SOAP note'' activities were added to the curriculum. Students' performance on the SOAP notes were assessed by a team of evaluators. At the end of the semester, students and evaluators completed separate 6-item survey instruments concerning the usefulness of the IMC system in meeting the course objectives. Assessment. Students' performance on documentation activities improved over the course of the semester: 87% of the students avoided repeating previous mistakes by their final documentation activity. The vast majority of the students and evaluators found the system easy to use and the activities helpful. Conclusion. The development, implementation, and initial expansion of the IMC system across both laboratory and pharmacotherapy courses was a success. Continued integration into clinical coursework is planned and will further expand opportunities for applied learning experiences to prepare students for their experiential program and beyond.

Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE

“…Brown and colleagues observed that lower quality assessment and plan sections were seen on the first note (54% needed improvement), although that improved with each successive attempt (27% needed improvement by the fourth note, p<.001), and errors in assessment occurred twice as often as in the plan section (20.5% vs. 10.5% of notes, respectively) of the SOAP note. 5 Other studies have also noted that assessment documentation is more often incomplete versus other sections of the note. 7,16 The findings of our study A J P E A c c e p t e d D r a f t align with early curriculum studies in which students consistently struggled with the assessment sections, but that repeated SOAP note writing opportunities improved students' confidence and abilities.…”

“…Brown, et al's incorporation of the SOAP note format during a third-year pharmacotherapy course showed that overall mean SOAP note scores improved from 3.23 to 3.62 (out of 4) from the first to the fourth note (p<.001). 5 Students consistently struggle with proper assessment of patient care goals. On each SOAP note, the lowest scores seen were in the assessment section, which is consistent with other studies.…”

“…7,16 The findings of our study A J P E A c c e p t e d D r a f t align with early curriculum studies in which students consistently struggled with the assessment sections, but that repeated SOAP note writing opportunities improved students' confidence and abilities. [4][5][6]16 Grading rubrics are not only useful tools to evaluate student performance and provide formative assessments; studies have shown that students perceive the use of rubrics to be fair and transparent. 10 In this study, incorporation of a SOAP note rubric in APPEs improved student understanding of expectations for documentation and positively impacted student perception of SOAP note assessment and formative feedback by the preceptor.…”

“…To date, studies evaluating student pharmacists' clinical documentation have been conducted only in the early portion of curricula. [4][5][6][8][9] Student pharmacists are expected to have basic skills to effectively document patient care activities when entering advanced pharmacy practice experiences (APPE), yet a paucity of data exists evaluating the quality of student documentation during direct patient care experiences. Despite these challenges, students perceive the use of grading rubrics to be fair and transparent.…”

“…Using this approach encourages a specific clinical thought process and requires students to utilize critical thinking and problem solving skills. [5][6] A recent assessment of SOAP note evaluation tools examined assessment tools for SOAP notes used by laboratory instructors at colleges and schools of pharmacy. 7 There was a wide degree of variation in the tools and their content.…”