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Am J Kidney Dis. 2014 Nov;64(5):737-43. doi: 10.1053/j.ajkd.2014.06.027. Epub 2014 Aug 23.

Assessing achievement in nephrology training: using clinic chart audits to quantitatively screen competency.

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Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD. Electronic address:
Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD.



Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.


Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool.


Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years.


Proportion of chart audit and quality indicator deficiencies.


Longitudinal deficiency and ITE performance.


Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P<0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P<0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P<0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue.


Retrospective design and small trainee numbers.


Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.


Chart audit; competencies; educational outcomes; entrustable professional activities (EPAs); fellowship; graduate medical education; milestones; nephrology; training programs

[Indexed for MEDLINE]

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