Application of SOAP assessment note to rehabilitation therapy teaching

doi:10.3969/j.issn.2095-4344.2015.05.026

Abstract

Abstract:

BACKGROUND: In rehabilitation therapy teaching, it is crucial to cultivate professional knowledge and clinical skills of rehabilitation therapy for students. SOAP (Subjective, Objective, Assessment, Plan) is the international most commonly used and accepted in the medical records of problem oriented method. SOAP is used to develop clinical thinking ability, improve analysis, judgment and the ability of solving clinical problem for students.
OBJECTIVE: To retrospectively analyze the composition, teaching benefit and problems of SOAP in China.
METHODS: Published articles about SOAP note were searched from PubMed, Web of Science and China National Knowledge Infrastructure, and the articles were retrieved from database building to September 2014. The key words were “SOAP note, rehabilitation, teaching” in Chinese and English. We excluded the repetitive researches.
RESULTS AND CONCLUSION: After screening, we included 20 articles in the review. SOAP note was helpful to promote students’ independent thinking, strengthened the standardization of the records, rehabilitation treatment, and developed the students’ clinical thinking and the ability to deal with the problem. SOAP note has several challenges in the rehabilitation teaching, however, with the popularity of SOAP teaching concept, and deep research and gradual generalization of SOAP teaching methods, SOAP has a wide application prospect for the rehabilitation education in China.

中国组织工程研究杂志出版内容重点：肾移植；肝移植；移植；心脏移植；组织移植；皮肤移植；皮瓣移植；血管移植；器官移植；组织工程

全文链接：

Key words: Tissue Engineering, Assessment, Rehabilitation, Therapy, Teaching, Application

CLC Number:

R318

Wang Xue-qiang, Wang Ru, Chen Pei-jie . Application of SOAP assessment note to rehabilitation therapy teaching[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(5): 805-809.

Figures/Tables 1

2.1 纳入资料基本概况共检索到43篇相关文献。排除重复论文，以及经阅读标题、摘要和全文后，纳入20篇文献进行分析总结[1-20]。其中5篇文献来自中国[5-9]，其他来自国外相关文献[1-4，10-20]。 2.2 纳入资料的研究结果特征 2.2.1 SOAP评估记录法概述康复评估应该是从临床康复人员的视角和患者的视角去理解患者主诉的功能障碍，进而系统、全面、清晰地认识患者的主要问题，只有通过恰当、全面系统的检查才能对患者的功能障碍做完整的评估。目前国内外最公认的评估记录方法是以问题为导向的医学记录方法，即SOAP评估记录[1-9]。研究证实：SOAP评估记录方法具有良好的信度和效度、且简单实用。SOAP包含4个方面：主观资料(Subjective，S)，客观资料(Objective，O)，评估(Assessment，A)和计划(Plan，P)[10-11]。主观资料(Subjective，S) 主要是患者提供的资料，包括患者主诉，一般情况(例如年龄、职业等)、疾病发生发展情况、当前症状、个人病史、家族病史等。主观资料的获得主要通过临床问诊，临床问诊实质是资料的搜集、思考、质疑并整合患者提供的相关信息以得出康复评估和治疗方案的临床推理过程。临床推理不仅仅是康复治疗学科需要理解的概念，更是需要康复医师和治疗师学习的临床技能。康复医务人员在评估时，需明确以下问题[21]：患者的年龄、性别、从事的职业、什么部位出现症状、如何损伤的、症状程度及持续时间、哪些姿势或动作会加重或减轻症状、是否影响生活自理能力、是否影响到睡眠等。举例一：患者的年龄。许多疾病是与年龄呈相关性的。例如，不同年龄导致腰痛疾病的种类不同：①小儿和青少年导致腰痛常见疾病为先天性畸形、脊柱侧弯等。②中青年导致腰痛常见疾病为腰肌劳损、腰扭伤、腰椎间盘突出症等。③老年导致腰痛常见疾病为腰椎骨性关节炎、腰椎管狭窄、骨质疏松等。举例二：患者的职业。不同职业导致疾病的种类不同。例如，不同职业与膝关节疼痛：①跑步运动员导致膝关节疼痛常见疾病为“跑步膝”(即髌骨软骨损伤)。②篮球运动员导致膝关节疼痛常见疾病为“篮球膝”(即髌腱末端病)。客观资料(Objective，O)是指康复医务人员在康复评估过程中所观察的信息，即主要是通过视诊发现患者的功能障碍与所观察的信息的相关性。检查者在观察患者姿势时，尽量明确以下问题：从前面看，鼻、胸骨剑突和肚脐是否在一条直线上；从侧面看，颞骨外缘、肩峰、髂脊、膝关节和外踝稍前方是否在一条直线上[22]；肢体上否存在畸形；肢体位置是否对等和平衡；是否存在红、肿、热；患者对功能障碍的态度；患者是否愿意活动；患者活动时的表情等。举例一：肢体是否处于中立位：如从侧面观察腰椎，腰椎呈现前凸，骨盆倾斜角增大，可能存在的肌肉失衡为腰部伸展肌群和屈髋肌群变紧张，腹部肌群与伸髋肌群变松弛。举例二：肢体位置是否对等和平衡：如从后面观察肩胛骨，两侧肩胛骨下角距离脊柱的距离为不等长，一侧肩胛下角向外旋并远离脊柱中线，可能存在的肌肉失衡为前锯肌、斜方肌下部纤维、菱形肌较对侧薄弱[23-24]。评估(Assessment，A)是为了排除或确诊前面根据主观资料和客观资料所做的初步诊断，故这些评估需要系统地进行。若患者的病情是急性的，评估者需要细心。康复医务人员在为患者评估时，需遵循以下原则[25]：一般先做健侧的评估；先做主动活动评估，再做被动活动评估，最后做等长抗阻评估；引起疼痛的活动最后检查；关节活动范围受限的肢体，需仔细加压以体验最末端感觉(End feel)等。同时也应注意在评估某个部位或关节时，检查者还需注意此部位或关节的损伤，是否会对完整运动链上的其他关节所造成影响，以及是否发生代偿的变化等。举例：颈椎病患者的评估主要包含以下方面：①颈椎的主动活动、被动活动和等长抗阻运动。②颈髓神经节检查(C5：屈肘肌群)。③颈椎的特殊检查，如椎间孔压迫试验、上肢张力试验。④反射检查，如Hoffmann试验。⑤日常生活能力评定(activies of daily living，ADL)与功能性评估，如Barthel指数评定、颈椎功能障碍指数(neck disability index)。计划(Plan，P)该部分是针对患者存在的功能障碍所制定康复治疗计划，并拟定近期康复目标与远期目标。一段时间治疗后，再次进行康复评估，根据患者的功能障碍调整康复治疗方案。 2.3 SOAP评估记录法引入康复治疗教学中的益处在当前严峻的医疗环境下，如何让学生较好地掌握康复治疗理论、知识和临床康复技能已成为教学中面临的难题。培养优秀的康复医务人员，必须提高其自主思考能力、临床推理能力和解决临床康复问题的综合能力。笔者认为SOAP评估记录法引入康复治疗教学，会带来以下几方面益处： 2.3.1 提高学生的临床推理能力较多的康复治疗学生和年轻的康复医务人员，通过在高校已经学习了大量康复基础知识和临床康复基本技能，但到医院遇见具体的患者、具体的功能障碍，却仍不知所措。这主要是因为缺乏临床推理能力，灵活应用知识、解决实际具体问题的能力明显不够。美国Davis等[16]认为临床推理能力是物理治疗师最重要的技能之一。新西兰Mass等[17]强调物理治疗师的临床推理能力在康复治疗中至关重要。SOAP评估记录法引入康复治疗学科，则要求康复医务人员采集和分析患者提供的主观资料、检查者观察的客观资料、全面系统评估患者存在的功能障碍问题、制定合适的康复治疗方案。 SOAP的4个方面都始终贯穿着临床推理能力的思想[18]，SOAP评估记录既是康复医务人员记录的一种格式，也是分析问题、解决问题的一种思路，故该方法可有利于扩宽学生的临床推理能力。 2.3.2 加强康复记录、治疗的规范化 SOAP评估记录法要求学生按照S-O-A-P程序去思考，先逐条理出主观、客观资料，然后再对功能障碍问题进行评估，最后做出康复治疗计划。康复医务人员通过这一程序，不仅思考的问题会比较有条理，问题看得比较深，而且将把康复记录、治疗执行的更加规范[19-20]，这对将来的临床康复工作大有裨益。康复治疗的规范化具体体现为康复治疗记录，康复医务人员只有标准的康复评估和治疗并进行合理的记录，才能有利于康复治疗的具体执行。通过规范化的SOAP评估记录和治疗，可以不断的自主发现问题，自主解决问题，促使康复医务人员的评估能力、康复技术水平以及整体综合实力才能不断提高。 2.3.3 提高自学能力 SOAP评估记录引入康复治疗教学中，是以问题为导向的临床教学，其主要环节是需要学生联系患者的症状与功能障碍，提出问题、评估及制定康复治疗计划。 SOAP评估记录法在康复治疗教学中，更需要康复治疗教师由传统的“以教师为中心”的教学模式转变为“以学生为中心”的教学模式，即教师要成为学生学习活动的参与者、指导者和组织者，以便提高学生对康复评估与治疗的兴趣，和对康复治疗课程的参与度。例如，康复治疗教师在课堂中引入一案例，组织、引导学生采用SOAP评估记录法对案例进行分析，学生面对具体案例，通过分析、讨论，并带着问题进行思考与学习，同时对患者的功能障碍及转归、康复治疗方案等进行系统学习，加深了对临床康复基本知识的理解，做到了理论与实践相结合，最终也锻炼了学生自主获取知识的能力，使学生在未来工作实践中面临新问题时，能通过各种方法解决临床康复问题。"

References

[1] Weiss PM, Lara-Torre E, Murchison AB, et al. Expanding the SOAP Note to SOAPS (With S for Safety): A New Era in Real-time Safety Education. J Grad Med Educ. 2009;1(2): 316-318.
[2] Reznich CB, Wagner DP, Noel MM. A repurposed tool: the Programme Evaluation SOAP Note. Med Educ. 2010;44(3): 298-305.
[3] Sleszynski SL, Glonek T. Outpatient Osteopathic SOAP Note Form: preliminary results in osteopathic outcomes-based research. J Am Osteopath Assoc. 2005;105(4):181-205.
[4] Friedsam D, Rieselbach R. The ailing health care system: SOAP note for physician leadership. WMJ. 2008; 107(8): 363-366.
[5] 彭浩.SOAP式问题描述法在中医内科临床见习课的应用[J].中医药管理杂志, 2012,20(6):588-589.
[6] 陈凤莲,赵爱兰.“SOAP”评估法在急诊病人分诊中的实践[J].国际医药卫生导报,2009,15(3):8-9.
[7] 王勤荣,吴国球,倪卫子.SOAP式问题描述在临床教学中的应用[J].中等医学教育,1999,17(1):35-36.
[8] 周昕. SOAP药历在医院药学教学活动中的应用[J].卫生职业教育,2012,30(23):64-65.
[9] 李奎,窦祖林,万桂芳,等.基于SOAP格式的康复治疗记录软件的设计与应用[J].中国康复,2007,22(5):340-341.
[10] Mowery D, Wiebe J, Visweswaran S, et al. Building an automated SOAP classifier for emergency department reports. J Biomed Inform. 2012;45(1):71-81.
[11] Sanfilippo JS. Infertility classification: a work in progress sounds like SOAP revisited. Fertil Steril. 2005;83(4):842-843.
[12] Kolluru S, Roesch DM, Akhtar de la Fuente A. A multi-instructor, team-based, active-learning exercise to integrate basic and clinical sciences content. Am J Pharm Educ. 2012;76(2):33.
[13] Aronson L, Niehaus B, Lindow J, et al. Development and pilot testing of a reflective learning guide for medical education. Med Teach. 2011;33(10):515-521.
[14] Sobieraj DM, McCaffrey D, Lee JJ. Redesign and evaluation of a patient assessment course. Am J Pharm Educ. 2009; 73(7):133.
[15] Turner MK, Simon SR, Facemyer KC, et al. Web-based learning versus standardized patients for teaching clinical diagnosis: a randomized, controlled, crossover trial. Teach Learn Med. 2006;18(3):208-214.
[16] Davis DS. Teaching professionalism: a survey of physical therapy educators. J Allied Health. 2009;38(2):74-80.
[17] Maas MJ, Sluijsmans DM, van der Wees PJ, et al. Why peer assessment helps to improve clinical performance in undergraduate physical therapy education: a mixed methods design. BMC Med Educ. 2014;14:117.
[18] Cillessen FH, de Vries Robbé PF. Modeling problem-oriented clinical notes. Methods Inf Med. 2012;51(6):507-515.
[19] Ilan R, LeBaron CD, Christianson MK, et al. Handover patterns: an observational study of critical care physicians. BMC Health Serv Res. 2012;12:11.
[20] Jacks ME, Blue C, Murphy D. Short- and long-term effects of training on dental hygiene faculty members' capacity to write SOAP notes. J Dent Educ. 2008;72(6):719-724.
[21] David JM. Orthopedic Physical Assessment, 5th Edition. Singapore: Elsevier. 2007; 2-12.
[22] Page P, Lardner R, Frank C. Assessment and treatment of muscle Imbalance: The Janda Approach. America: Human Kinetics Publishers. 2010;51-71.
[23] Yoo WG, Yi CH, Kim MH. Effects of a ball-backrest chair on the muscles associated with upper crossed syndrome when working at a VDT. Work. 2007;29(3):239-244.
[24] Valli J. Chiropractic management of a 46-year-old type 1 diabetic patient with upper crossed syndrome and adhesive capsulitis. J Chiropr Med. 2004;3(4):138-144.
[25] Miller KJ, Sittler MD, Corricelli DM, et al. Combination testing in orthopedic and neurologic physical examination: a proposed model. J Chiropr Med. 2007;6(4):163-171.
[26] Berry EM. The role of the sociotype in managing chronic disease: integrating bio-psycho-sociology with systems biology. Med Hypotheses. 2011;77(4):610-613.
[27] Vargus-Adams JN, Majnemer A. International Classification of Functioning, Disability and Health (ICF) as a Framework for Change: Revolutionizing Rehabilitation. J Child Neurol. 2014; 29(8):1030-1035.
[28] de Boer W, Danelia M, Zurabashvili D, et al. Development of a training programme in disability assessment methidology based on international classification of functioning, disability and health (icf) for psychiatric disability claims in Georgia. Georgian Med News. 2014;(232-233):74-77.
[29] Forget NJ, Higgins J. Comparison of generic patient-reported outcome measures used with upper extremity musculoskeletal disorders: linking process using the International Classification of Functioning, Disability, and Health (ICF). J Rehabil Med. 2014;46(4):327-334.
[30] Petrovic B, Markovic D, Peric T. Evaluating the population with intellectual disability unable to comply with routine dental treatment using the International Classification of Functioning, Disability and Health. Disabil Rehabil. 2011;33(19-20): 1746-1754.
[31] Kato-Lin YC, Krishnamurti L, Padman R, et al. Does e-pain plan improve management of sickle cell disease associated vaso-occlusive pain crisis? A mixed methods evaluation. Int J Med Inform. 2014;83(11):814-824.
[32] Fisker MH, Agner T, Lindschou J, et al. Protocol for a randomised trial on the effect of group education on skin-protective behaviour versus treatment as usual among individuals with newly notified occupational hand eczema - the Prevention of Hand Eczema (PREVEX) Trial. BMC Dermatol. 2013;13:16.
[33] Neri PM, Volk LA, Samaha S, et al. Relationship between documentation method and quality of chronic disease visit notes. Appl Clin Inform. 2014;5(2):480-490.
[34] Wright A, Sittig DF, McGowan J, et al. Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record. J Am Med Inform Assoc. 2014;21(6):964-968.
[35] Morgan KA, Gottlieb M, Hollingsworth HH, et al. Work environments of people with mobility impairments and limitations: Mobility Device User Work Survey (MWS). Work. 2014;48(3):339-348.
[36] Helstrom JM, Langenau EE, Sandella JM, et al. Keyboard data entry use among osteopathic medical students and residents. J Am Osteopath Assoc. 2014;114(4):274-282.
[37] Dunleavy L, Preissner KL, Finlayson ML. Facilitating a teleconference-delivered fatigue management program: perspectives of occupational therapists. Can J Occup Ther. 2013;80(5):304-313.
[38] Lenert LA, Sakaguchi FH, Weir CR. Rethinking the discharge summary: a focus on handoff communication. Acad Med. 2014;89(3):393-398.
[39] Pokharel M, Karki S, Shrestha BL, et al. Correlations between symptoms, nasal endoscopy computed tomography and surgical findings in patients with chronic rhinosinusitis. Kathmandu Univ Med J (KUMJ). 2013;11(43):201-205.
[40] Sandella JM, Smith LA, Gallagher LA, et al. Patterns of misrepresentation of clinical findings on patient notes during the COMLEX-USA Level 2-PE. J Am Osteopath Assoc. 2014;114(1):22-29.