摘要目的:探究反思教学结合国际功能、残疾和健康分类（儿童和青少年版）[International Classification of Functioning: Disability and Health（Children and Youth Version，ICF-CY）]框架下的SOAP（subjective objective assessment plan）病例记录法在康复治疗学实习中的应用效果。方法:将康复治疗学实习学生随机分为ICF-CY记录组和传统记录组，分别采用反思教学结合ICF-CY框架的SOAP病例记录法和传统SOAP病例记录法对脑瘫患儿进行病例分析。实习结束对两组学生进行病例考核及问卷调查。采用SPSS 20.0对数据进行 t检验和卡方检验。 结果:病例考核成绩显示ICF-CY组在客观资料、评估、计划、总结及总成绩方面均高于传统记录组；调查问卷显示学生对反思教学结合ICF-CY框架下的SOAP病例记录法评价优于传统SOAP记录法（ P<0.001）。 结论:反思教学结合ICF-CY框架的SOAP病例记录法能提高学生的临床病例分析能力，激发学生的自主学习能力，有利于培养临床诊疗思维。

abstractsObjective:To explore the effects of SOAP (subjective objective assessment plan) case recording method by reflective teaching combined with the framework of International Classification of Functioning-Children and Youth Version (ICF-CY) in rehabilitation therapy practice.Methods:Interns of rehabilitation therapywere randomly divided into ICF-CY record group taking the case recording method of reflective teaching combined with the framework of ICF-CY and traditional record group taking traditional SOAP case recording method for children with cerebral palsy. After the internship, examination based on the clinical analysis and assessment of cases records and questionnaire survey were conducted among the two groups of interns. SPSS 20.0 was used to conduct t test and chi-square test. Results:The scores based on the clinical analysis and assessment of the ICF-CY record group were higher than those of the traditional record group. The questionnaire showed that interns' satisfaction of the SOAP case recording method by reflective teaching combined with the framework of ICF-CY was superior to the traditional SOAP case recording method ( P<0.001). Conclusion:The SOAP case recording method by reflective teaching combined with the framework of ICF-CY can improve interns' abilities of clinical case analysis, stimulate their self-learning abilities, and help to cultivate their thinking of clinical diagnosis and treatment.