Lost in translation: Unveiling medical students' untold errors of medical history documentation.
Journal
The clinical teacher
ISSN: 1743-498X
Titre abrégé: Clin Teach
Pays: England
ID NLM: 101227511
Informations de publication
Date de publication:
03 Mar 2024
03 Mar 2024
Historique:
received:
15
08
2023
accepted:
31
01
2024
medline:
4
3
2024
pubmed:
4
3
2024
entrez:
4
3
2024
Statut:
aheadofprint
Résumé
The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting. In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness. Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category personal details overlapped with 94.2% between students' report and ground truth in contrast to the main category with the highest discrepancy, allergy, with 41.1% overlap. Pertinent negative items and non-numerical quantifications were often missed. Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd.
Références
Cusack CM, Hripcsak G, Bloomrosen M, Rosenbloom ST, Weaver CA, Wright A, et al. The future state of clinical data capture and documentation: a report from AMIA's 2011 policy meeting. J am Med Inform Assoc. 2013;20(1):134-140. https://doi.org/10.1136/amiajnl-2012-001093
Liang JW, Shanker VL. Education in neurology resident documentation using payroll simulation. J Grad Med Educ. 2017;9(2):231-236. https://doi.org/10.4300/JGME-D-16-00235.1
Patenaude AF, Pelletier W, Bingen K. Communication, documentation, and training standards in pediatric psychosocial oncology. Pediatr Blood Cancer. 2015;62(Suppl 5):S870-S895. https://doi.org/10.1002/pbc.25725
Koh J, Ahmed M. Improving clinical documentation: introduction of electronic health records in paediatrics. BMJ Open Qual. 2021;10(1):e000918. https://doi.org/10.1136/bmjoq-2020-000918
Association of American Medical Colleges, Core entrustable professional activities for entering residency, 2014. https://store.aamc.org/downloadable/download/sample/sample_id/63/
M. Fakultätentag, Nationaler Kompetenzbasierter Lernzielkatalog Medizin - Version 2.0, 2021. http://nklm.de
Keifenheim KE, Teufel M, Ip J, Speiser N, Leehr EJ, Zipfel S, et al. Teaching history taking to medical students: a systematic review. BMC Med Educ. 2015;15(1):159. https://doi.org/10.1186/s12909-015-0443-x
Shoemaker MM, Lippold C, Schreiber R, Levy B. Novel application of telemedicine and an alternate EHR environment for virtual clinical education: a new model for primary care education during the SARS-CoV-2 pandemic. Int J Med Inform. 2021;153:104526. https://doi.org/10.1016/j.ijmedinf.2021.104526
Harendza S, Gärtner J, Zelesniack E, Prediger S. Evaluation of a telemedicine-based training for final-year medical students including simulated patient consultations, documentation, and case presentation. GMS J Med Educ. 2020;37(7):Doc94.
Aziz K, Sherif NA, Meshkin RS, Lorch AC, Armstrong GW. Telemedicine curriculum in an ophthalmology residency program. J Acad Ophthalmol. 2017;14(1):e93-e102. https://doi.org/10.1055/s-0042-1743580
Lange S, Krüger N, Warm M, Op den Winkel M, Buechel J, Huber J, et al. Online medical history taking course: opportunities and limitations in comparison to traditional bedside teaching, GMS. J Med Educ. 2022;39(3). PMID: Doc34.
Wilson BE. Performance-based assessment of internal medicine interns: evaluation of baseline clinical and communication skills. Acad Med. 2002;77(11):1158. https://doi.org/10.1097/00001888-200211000-00023
Kasai H, Shikino K, Saito G, Tsukamoto T, Takahashi Y, Kuriyama A, et al. Alternative approaches for clinical clerkship during the COVID-19 pandemic: online simulated clinical practice for inpatients and outpatients-a mixed method. BMC Med Educ. 2021;21(1):149. https://doi.org/10.1186/s12909-021-02586-y
Lai J, Tillman D. Curriculum to develop documentation proficiency among medical students in an emergency medicine clerkship. Med Ed Portal. 2021;17:11194.
Ferenchick GS, Solomon D, Mohmand A, Towfiq B, Kavanaugh K, Warbasse L, et al. Are students ready for meaningful use? Med Educ Online. 2013;18(1):22495. https://doi.org/10.3402/meo.v18i0.22495
Weiner SJ, Wang S, Kelly B, Sharma G, Schwartz A. How accurate is the medical record? A comparison of the physician's note with a concealed audio recording in unannounced standardized patient encounters. J Am Med Inform Assoc. 2020;27(5):770-775. https://doi.org/10.1093/jamia/ocaa027
Rodríguez-Fernández JM, Loeb JA, Hier DB. It's time to change our documentation philosophy: writing better neurology notes without the burnout. Front Digit Health. 2022;4:1063141. https://doi.org/10.3389/fdgth.2022.1063141
van Dijk DA, Oostindiër MJ, Kloosterman-Boele WM, Krijnen P, Vasen HF. Family history is neglected in the work-up of patients with colorectal cancer: a quality assessment using cancer registry data. Fam Cancer. 2007;6(1):131-134. https://doi.org/10.1007/s10689-006-9114-8
Langewitz WA, Loeb Y, Nübling M, Hunziker S. From patient talk to physician notes-comparing the content of medical interviews with medical records in a sample of outpatients in internal medicine. Patient Educ Couns. 2009;76(3):336-340. https://doi.org/10.1016/j.pec.2009.05.008
Saravi BM, Asgari Z, Siamian H, Farahabadi EB, Gorji AH, Motamed N, et al. Documentation of medical records in hospitals of Mazandaran University of Medical Sciences in 2014: a quantitative study. Acta Inform Med. 2016;24(3):202-206. https://doi.org/10.5455/aim.2016.24.202-206
Zorn J, Snyder J, Guthrie J. Use of moulage to evaluate student assessment of skin in an objective structured clinical examination. J Physician Assist Educ. 2018;29(2):99-103. https://doi.org/10.1097/JPA.0000000000000205
Bynum D, Colford C, Royal K. Teaching medical students the art of the ‘write-up’. Clin Teach. 2015;12(4):246-249. https://doi.org/10.1111/tct.12304
J. Seiderer-Nack, A. Sternfeld, Anamnese und körperliche Untersuchung, 2018.
McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22(3):276-282.
Treloar EC, Ting YY, Kovoor JG, Ey JD, Reid JL, Maddern GJ. Can checklists solve our ward round woes? A systematic review. World J Surg. 2022;46(10):2355-2364. https://doi.org/10.1007/s00268-022-06635-5
Walling A, Moser SE, Dickson G, Zackula RE. Are students less likely to report pertinent negatives in post-encounter notes? Fam Med. 2012;44(1):22-25.
Hermasari BK, Nugroho D, Maftuhah A, Pamungkasari EP, Budiastuti VI, Laras AA. Promoting medical student's clinical reasoning during COVID-19 pandemic. Korean J Med Educ. 2023;35(2):187-198. https://doi.org/10.3946/kjme.2023.259
Hawkins J, Blakeslee S. On Intelligence St. Martin's Griffin; 2005.
Kahneman D. Thinking, fast and slow Farrar, Straus and Giroux; 2011.
Szauter KM, Ainsworth MA, Holden MD, Mercado AC. Do students do what they write and write what they do? The match between the patient encounter and patient note. Acad Med. 2006;81(10 Suppl):S44-S47. https://doi.org/10.1097/00001888-200610001-00012
Heiman HL, Rasminsky S, Bierman JA, Evans DB, Kinner KG, Stamos J, et al. Medical students' observations, practices, and attitudes regarding electronic health record documentation. Teach Learn Med. 2014;26(1):49-55. https://doi.org/10.1080/10401334.2013.857337
Rowlands S, Coverdale S, Callen J. Documentation of clinical care in hospital patients' medical records: a qualitative study of medical students' perspectives on clinical documentation education. Health Inf Manag. 2016;45(3):99-106. https://doi.org/10.1177/1833358316639448
Rousseau M, Könings KD, Touchie C. Overcoming the barriers of teaching physical examination at the bedside: more than just curriculum design. BMC Med Educ. 2018;18(1):302. https://doi.org/10.1186/s12909-018-1403-z
Farooqi M, Aljibury O, Arfeen F, Syed U, Cheema H, Choudri M. Using OSCEs to test students' documentation skills. Clin Teach. 2017;14(1):65-67. https://doi.org/10.1111/tct.12511
Bruner A, Kasdan ML. Handwriting errors: harmful, wasteful and preventable. J Ky Med Assoc. 2001;99(5):189-192.
Haworth S, Bates AS, Beech A, Knepil G. Quality improvement in documentation for patients with suspected facial fractures: use of a structured record keeping tool. Emerg Med J. 2016;33(4):268-272. https://doi.org/10.1136/emermed-2015-205141
Baumann LA, Baker J, Elshaug AG. The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy. 2018;122(8):827-836. https://doi.org/10.1016/j.healthpol.2018.05.014
Witkowski C, Kimmel L, Edwards E, Cosic F. Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients. Aust Health Rev. 2022;46(2):204-209. https://doi.org/10.1071/AH21112
Mintz M, Narvarte HJ, O'Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med. 2009;84(12):1698-1704. https://doi.org/10.1097/ACM.0b013e3181bf9d45
Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-224. https://doi.org/10.1080/10401334.2012.692267
McCarthy B, Fitzgerald S, O'Shea M, Condon C, Hartnett-Collins G, Clancy M, et al. Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. J Nurs Manag. 2019;27(3):491-501. https://doi.org/10.1111/jonm.12727
Leunig A, Winkler M, Gernert JA, Graupe T, Dimitriadis K. Management lessons through an interactive online discussion about hospital management during the COVID-19 pandemic. GMS J Med Educ. 2021;38(1):Doc25.