Development and validation of an objective structured SOAP notes assessment (OS-SOAPNA) for general surgery interns in a tertiary care setting

Date of Award

8-27-2025

Degree Type

Thesis

Degree Name

Master of Health Professions Education

First Advisor

Dr Amber Sultan

Second Advisor

Dr Riazuddin Biyabani

Third Advisor

Dr Qamar Riaz

Department

Educational Development

Abstract

Background: Structured and accurate postoperative progress notes are vital for detecting early complications, monitoring recovery, and standardizing medical records. The Subjective, Objective, Assessment, and Plan (SOAP) template is widely used. During surgical rotations, interns are responsible for assessing and documenting the clinical encounters of postoperative patients. However, national and international studies have consistently highlighted inadequate in the completeness and accuracy of postoperative progress notes written by interns. At present, no validated tool exists for the formative assessment of surgical interns, postoperative documentation.
Objective: To develop and validate the objective structured SOAP notes assessment (OS-SOAPNA) tool for assessing SOAP notes written by general surgery interns for postoperative patients.
Methods: This tool validation study was conducted from march to august 2025 in the Department of surgery at a tertiary care hospital in Lahore. Tool items were generated through literature review and refined via a two-round modified Delphi technique involving six consultant surgeons and one medical educationist. Content validity index was calculated at both items and scale levels. After pilot testing, forty interns were enrolled. Each intern completed two SOAP notes for different postoperative patients. Six pairs of trained assessors assessed SOAP notes using OS_SOAPNA. Descriptive statistics were used to determine interns’ performance across SOAP notes’ components. Inter-rater reliability was determined in terms of intraclass correlation coefficients and weighted Cohen’s kappa. While internal consistency was assessed through Cronbach’s alpha. Item analysis was also performed.
Results: The validated OS-SOAPNA included patient’s demographic, operative information, and intern’s identifiers in addition to the subjective, objective, assessment, and plan domains. The lowest mean score, with the greatest variability, was observed in the wound and dressing examination component (3.04*1.85). Most SOAP notes were rated borderline or pass, with only one rated excellent. Content validity was excellent, well above the predetermined threshold. Inter-rater reliability was high ( overall ICC 0.930). Kappa values indicated substantial agreement (0.61-0.80). Cronbach’s alpha was acceptable (0.762). Items analysis suggested that the wound and dressing examination, medications, and credentials components contributed the least to internal consistency.
Conclusion: OS-SOAPNA is a valid and reliable formative assessment tool for postoperative SOAP notes by surgical interns. Its use improve documentation quality and supports structured feedback.

First Page

1

Last Page

174

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