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

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

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.

Publication types

  • Evaluation Study

MeSH terms

  • Adult
  • Clinical Clerkship / standards*
  • Clinical Competence / standards*
  • Curriculum
  • Education, Medical, Undergraduate / standards*
  • Female
  • Humans
  • Male
  • Medical History Taking / methods*
  • Patient Education as Topic / standards*
  • Pennsylvania
  • Physical Education and Training / methods*
  • Reproducibility of Results
  • Students, Medical*