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.
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Purpose The purpose of this study was evaluation of the current status of medical students' documentation of patient medical records.
Methods We checked the completeness, appropriateness, and accuracy of 95 Subjective- Objective -Assessment-Plan (SOAP) notes documented by third-year medical students who participated in clinical skill tests on December 1, 2014. Students were required to complete the SOAP note within 15 minutes of an standard patient (SP)-encounter with a SP complaining rhinorrhea and warring about meningitis.
Results Of the 95 SOAP notes reviewed, 36.8% were not signed. Only 27.4% documented the patient’s symptoms under the Objective component, although all students completed the Subjective notes appropriately. A possible diagnosis was assessed by 94.7% students. Plans were described in 94.7% of the SOAP notes. Over half the students planned workups (56.7%) for diagnosis and treatment (52.6%). Accurate documentation of the symptoms, physical findings, diagnoses, and plans were provided in 78.9%, 9.5%, 62.1%, and 38.0% notes, respectively.
Conclusion Our results showed that third-year medical students’ SOAP notes were not complete, appropriate, or accurate. The most significant problems with completeness were the omission of students’ signatures, and inappropriate documentation of the physical examinations conducted. An education and assessment program for complete and accurate medical recording has to be developed.
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Purpose Information gathering ability had been evaluated mainly via checklists in clinical performance examinations (CPX). But, it is not proved yet if students write the information correctly in postencounter note (PN), although they asked questions or performed physical examinations (PE) about the information when they interacted with standardized patients in CPX. This study addressed the necessity of introducing PN to evaluate the ability in CPX.
Methods After patient encounters, students were instructed to write the findings of history taking and physical examination that they considered as important information in approaching the patient’s problems in PN. PNs were scored using answer keys selected from checklist items, which were considered to be recorded in PN by CPX experts.
Results PNs of six CPX cases from 54 students were analyzed. Correlation coefficients between the key-checklist scores and PN scores of six cases were moderate to high (0.52 to 0.79). However, students frequently neglected some cardinal features of chief complains, pertinent findings of past/social history and PE, and pertinent negative findings of associated symptoms in PNs, which were checked as ‘done’ in the keys of checklists.
Conclusion It is necessary to introduce PN in CPX to evaluate the students’ ability of synthesis and integration of patient information.
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