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Teach Learn Med. 2008 Jan-Mar;20(1):31-6. doi: 10.1080/10401330701798253.

Evaluation of the congruence between students' postencounter notes and standardized patients' checklists in a clinical skills examination.

Author information

  • 1Clinical Skills Center, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA. Katherine.Worzala@jefferson.edu

Abstract

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.

PMID:
18444183
[PubMed - indexed for MEDLINE]
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