Award Date

5-1-2025

Degree Type

Doctoral Project

Degree Name

Occupational Therapy Doctorate

Department

Brain Health

First Committee Member

Donnamarie Krause

Second Committee Member

Sharon Jalene

Number of Pages

99

Abstract

Objective: This capstone project evaluated the feasibility of integrating EHR Go and Unfolding Case Studies (UCS) into the first-year curriculum of the University of Nevada, Las Vegas (UNLV) Occupational Therapy Doctorate (OTD) program. The goal was to enhance students’ SOAP (Subjective, Objective, Assessment, Plan) note documentation proficiency and critical thinking skills through simulation-based learning and increased exposure to real-world documentation expectations and examples. Feedback from 33 clinicians at Dignity Health St. Rose Dominican Hospital – Siena Campus informed the workshop design, and OTD faculty and graduate assistants at UNLV provided input on curriculum integration feasibility.Methods: A quasi-experimental, non-equivalent groups pretest-posttest design was used. Prior to the intervention, 33 clinicians participated in a documentation needs assessment to guide workshop development and content priorities. Twelve first-year OTD students voluntarily participated in a documentation workshop featuring EHR Go and UCS. The intervention included timed SOAP note writing, case-based scenarios, and feedback from instructors and peers. Pre- and post-intervention surveys measured students’ confidence in documentation, and SOAP note assignments were graded using a standardized rubric to assess objective proficiency. Scores were compared within the workshop group and against the remainder of the cohort (n = 15) who did not attend the workshop. Additionally, a SOAR analysis and staff interviews were conducted to evaluate curricular relevance and implementation feasibility. Findings: Clinician feedback emphasized the need for structured documentation training and validated the workshop’s content focus on clinical reasoning and EHR literacy. Statistically significant improvements in documentation confidence were observed for workshop participants in the Objective (p = .037), Assessment (p = .015), and Plan (p = .008) sections. Wilcoxon signed-rank tests showed that SOAP note scores improved significantly among participants (W = 0.0, p = .002, r = .88) and non-participants (W = 6.0, p = .003, r = .76), though workshop participants achieved a greater mean improvement (ΔM = 2.58 vs. 1.90). An independent samples t-test found no statistically significant difference between groups, t(25) = -1.20, p = .243, but a moderate between-group effect size (d = -0.46) suggested meaningful trends in favor of participants. Qualitative feedback further supported the workshop's effectiveness and curricular value, while faculty and graduate assistant responses confirmed that the workshop’s learning activities could feasibly be integrated into existing first-year coursework with appropriate support. Conclusion: The integration of EHR Go and UCS into the UNLV OTD curriculum was feasible and showed promising benefits for enhancing SOAP note proficiency and fieldwork preparedness. Findings support continued use of simulation-based documentation training to bridge academic instruction and clinical documentation demands.

Keywords

Clinical reasoning; Electronic health record simulation; Fieldwork preparation; Healthcare education; Occupational therapy curriculum; SOAP note writing

Disciplines

Medicine and Health Sciences | Occupational Therapy | Science and Mathematics Education

File Format

pdf

File Size

4200 KB

Degree Grantor

University of Nevada, Las Vegas

Language

English

Rights

IN COPYRIGHT. For more information about this rights statement, please visit http://rightsstatements.org/vocab/InC/1.0/

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