Table 3 Correlations of the components of the Patient Note Scoring and Clinical Reasoning Task instruments in 16 SOAP notes
Documentation of History and Physical Exam | Differential Diagnosis | Workup | |
|---|---|---|---|
Identify active issues | r = 0.233 p = 0.38 | r = 0.29 p = 0.27 | r = 0.329 p = 0.21 |
Consider alternative diagnoses and underlying cause(s) | r = 0.219 p = 0.41 | r = 0.091 p = 0.737 | r = − 0.63 p = 0.63 |
Identify precipitants or triggers to the current problem(s) | r = 0.047 p = 0.86 | r = − 0.291 p = 0.27 | r = 0.052 p = 0.84 |
Select diagnostic investigations | r = 0.141 p = 0.60 | r = 0.556* p = 0.025 | r = 0.462 p = 0.07 |
Determine the most likely diagnosis and underlying cause(s) | r = 0.177 p = 0.51 | r = 0.123 p = 0.65 | r = 0.22 p = 0.41 |
Identify modifiable risk factors | r = − 0.233 p = 0.38 | r = 0.097 p = 0.72 | r = 0.052 p = 0.84 |
Identify complications associated with the diagnosis, diagnostic investigations, or treatment | r = − 0.184 p = 0.495 | r = − 0.164 p = 0.544 | r = 0.068 p = 0.80 |
Explore physical and psychosocial consequences of the current medical conditions or treatment | r = 0.314 p = 0.23 | r = − 0.131 p = 0.62 | r = 0.07 p = 0.79 |
Establish goals of care | r = 0.304 p = 0.25 | r = − 0.21 p = 0.43 | r = 0.038 p = 0.89 |
Establish management plans | r = 0.288 p = 0.27 | r = 0.135 p = 0.61 | r = 0.073 p = 0.78 |
Determine follow-up and consultation strategies | r = 0.631** p = 0.009 | r = 0 p = 1 | r = 0.561* p = 0.041 |