There is a close relationship between the clinical progress of an illness and the physician's daily orders. The SOAP note is a means for healthcare providers to document The SOAP note is an acronym representing a widely used method of documentation for healthcare providers. Investigations, as well as differential diagnosis and planning used to write daily progress notes in the Subjective, Objective, Assessment, and Plan (SOAP) note format. Reflect what has been diagnosed over the past 24 hours and include new patient-reported content, new points obtained from inpatient examination and paraclinical One of the most important documents in medical records is the daily progress note, which presents the patient’s latest information and daily clinical progressĪs well as summarizing the ongoing evaluation done by the healthcare provider team and their plan and schedule for the patient. Medical records document the patient's condition, length of stay, examinations, treatments,Ĭlinical progress, and interactions between patient and healthcare providers during a course of treatment ( 2). ![]() Medical records can help healthcare providers in planning and evaluating the patients’ treatment process and ensuring theĬontinuity and quality of patient’s care by different healthcare providers. Planning health services, improving quality of health service, supporting the patients, supporting healthcare providers, as well as evaluating the health service delivery Medical records have various uses such as follow-up care, training, research, communicating with the staff involved in health care, providing information to organizations, Of progress note writing, before and after the intervention, were compared with paired sample t-test. Then, the same expert panel reviewed and assessed the newly written daily progress notes of the same medical interns. ![]() Training sessions (4 one-hour sessions) on how to write the daily progress note, based on SOAP format and its importance, were held for the interns. ![]() Content validity of the questionnaire was confirmed by experts and internal consistency was determined using Cronbach's alpha coefficient. In the baseline, daily progress notes written by 150 medical interns were assessed using a Subjective, Objective, Assessment, and Plan (SOAP)-based questionnaireīy the expert panel. This quasi-experimental study (pre- and post-test) was conducted on 150 medical interns selected through the census method at Razi Hospital of Rasht, north of Iran from
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