SOAP评估记录法在康复治疗教学中的应用

背景：在康复治疗教学中，培养学生康复治疗专业知识和临床康复技能是至关重要的。目前国际上最常用以问题为导向的医学记录方法，即SOAP (Subjective, Objective, Assessment, Plan)，以培养康复治疗专业学生的临床思维能力、提高学生分析、判断和解决临床康复问题的能力。 目的：回顾分析SOAP评估记录法的构成、在教学中的益处及在中国存在的问题。 方法：以电子检索方式对PubMed、Web of Science、中国知网数据库收录的有关SOAP评估记录法的研究文献，检索时间为从建库至2014年9月，检索词为“SOAP，康复，教学”和“SOAP note，rehabilitation，teaching”，排除重复类研究。 结果与结论：共纳入20篇文献，检索结果表明，SOAP教学模式有利于促进学生的自主思考，加强康复记录、康复治疗的规范化，更好地培养学生的临床思维和处理问题的能力。尽管SOAP评估记录法在康复治疗教学中存在的挑战，但随着SOAP教学理念的普及、教学方法的深入研究和逐步推广，将在中国康复治疗教育中有着更为广阔的应用前景。 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：

Application of SOAP assessment note to rehabilitation therapy teaching

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.