Purpose We not only developed a clinical practice program for the assessment and feedback vis-à-vis medical students’ medical records but also evaluated the effectiveness of this program via a self-assessment of medical students’ competence in writing medical records pre- and post-program.
Methods In 2022, 74 third-year medical students were divided into four groups and participated in a 2-week program. The students’ medical records were graded on a scale ranging from 1 to 3 daily, and the mean scores for 2 weeks were compared. Pre- and post-program, the students’ self-assessment survey was conducted.
Results The mean scores increased from 1.30 in the first week to 2.14 in the second week. The mean score of self-assessment showed significant improvements, increasing from 2.43 to 4.00 for medical record, 2.64 to 4.08 for write present illness, 2.08 to 3.89 for initial orders, 2.35 to 4.34 for signature, and 2.38 to 3.97 for consent (all p<0.001).
Conclusion We found that providing students with real-time assessment and feedback on their medical records increased their skills and confidence in medical records writing.
Citations
Citations to this article as recorded by
Effect of directly observed procedural skills amongst interns in documentation and certification of trauma Anupam Datta, Anamika Nath Medical Journal Armed Forces India.2025;[Epub] CrossRef
Teaching professional writing in prelicensure health professional education programs: a scoping review Patricia Morris, Rose McCloskey, Alexis McGill, Lisa Keeping-Burke, Alex Goudreau, Holly Knight, Sarah Buckley, David Mazerolle, Courtney Jones JBI Evidence Synthesis.2025; 23(10): 1938. CrossRef
Purpose The expertise of medicians in clinical decision-making is very important since it improves the quality of medical services provided to patients. This study analyzed the characteristics of the decision-making process and confirmed clinicians’ electroencephalography (EEG) characteristics by measuring their cerebral activity during clinical decision-making. This study aims to present learning directions for brain-based clinical decision-making to develop medical experts.
Methods This study was performed in the following two projects: (1) a qualitative study of clinical decision-making in a clinical scenario and (2) an analysis of differences in cortical activity of experts and novices through EEG.
Results In the 1st study, this study found that “confirmation of the patient’s chief complaints,” “physical examination,” and “radiography reading” steps, which showed the most prominent differences in the experts’ and novices’ decision making, were set as the significant steps of dentists’ clinical decision making. In the 2nd study, the experts’ and novices’ cortical activities were measured through a 32-channel EEG. In task 6, which had the lowest accuracy of diagnoses made by the experts, the brain activities in both groups were higher than in other tasks.
Conclusion This study developed and suggested a model of the decision-making process for experts and novices and suggested the basic directions for brain-based learning needed to raise experts based on brain activity.
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