| Autor: |
Worzala K, Rattner SL, Boulet JR, Majdan JF, Berg DD, Robeson M, Veloski JJ |
| Zdroj: |
Teaching & Learning in Medicine; Jan-Mar2008, Vol. 20 Issue 1, p31-36, 6p |
| Abstrakt: |
BACKGROUND AND PURPOSE: Questions remain about the congruence between students' written notes and checklists as summaries of encounters. METHODS: Students examined standardized patients and summarized findings in postencounter notes. The patients completed checklists. A physician read the students' notes and completed parallel checklists to document the history and physical items performed. Rates of under- and overdocumentation were calculated. RESULTS: Students documented findings for 71% of items performed - an underdocumentation rate of 29%. Approximately 94% of their documented findings were consistent with what they had done. Their rate of overdocumentation was 6%, in which they documented findings inconsistent with the checklists. About half the students had no instances of overdocumentation. CONCLUSION: Students' rate of underdocumentation was comparable to experienced clinicians. Although their overdocumentation rate was low overall, it was high for a few students. Evaluation of the congruence between checklists and postencounter notes provides useful information and informs checklist development. [ABSTRACT FROM AUTHOR] |
| Databáze: |
Complementary Index |
| Externí odkaz: |
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