SOAP Methodology in General Practice/Family Medicine Teaching in Practical Context.

INTRODUCTION: Medical records in General Practice/Family Medicine are an essential information support on the health status of the patient and a communication document between health professionals. The development of competencies in General Practice/Family Medicine during pre-graduation must include the ability to make adequate medical records in practical context. As of 2012, medicine students at the University of Beira Interior have been performing visits using the Subjective, Objective, Assessment and Plan - SOAP methodology, with a performance evaluation of the visit, with the aim to check on which Subjective, Objective, Assessment and Plan - SOAP aspects students reveal the most difficulties in order to define improvement techniques and to correlate patient grade with tutor evaluation.

MATERIAL AND METHODS: Analysing the evaluation data for the 2015 - 2016 school year at the General Practice/Family Medicine visit carried out by fourth year students in medicine, comparing the averages of each item in the Subjective, Objective, Assessment and Plan - SOAP checklist and the patient evaluation.

RESULTS: In the Subjective, Objective, Assessment and Plan - SOAP, 29.7% of students are on the best grade quartile, 37.1% are on the best competencies quartile and 27.2% on the best patient grade quartile. 'Evolution was verified/noted' received the worst grades in Subjective, 'Record of physical examination focused on the problem of the visit' received the worst grades in Objective, 'Notes of Diagnostic reasoning / differential diagnostic' received de worst grades in Assessment and 'Negotiation of aims to achieve' received the worst grades in Plan. The best tutor evaluation is found in 'communication'.

DISCUSSION: Only one single study evaluated student´s performance under examination during a visit, with similar results to the present one and none addressed the patient's evaluation.

CONCLUSION: Students revealed a good performance in using the Subjective, Objective, Assessment and Plan - SOAP. The findings represent the beginning of the introduction of the Subjective, Objective, Assessment and Plan - SOAP to the students. This evaluation breaks ground towards better ways to teach the most difficult aspects.