• Emerg Med Australas · Feb 2015

    Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital.

    • Jonathon Isoardi, Lyndall Spencer, Michael Sinnott, and Robert Eley.
    • Emergency Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
    • Emerg Med Australas. 2015 Feb 1; 27 (1): 6-10.

    ObjectivesThis study's objective was to determine whether tuition in medical documentation enhanced the ability of emergency medicine interns to produce effective medical records.MethodsThe study adopted a case control design, using a retrospective document audit methodology, following an education intervention during the 'More Learning for Interns in Emergency' (MoLIE) programme. It was conducted in a tertiary hospital that supports five 10 week rotations of 12 interns each year (n = 60). Controls were drawn from records written in March 2012 and cases from March 2013. A total of 250 medical records written by interns were audited, 125 from each year.ResultsThree categories of documentation were investigated: patient characteristics, clinical impressions and management plan using a purpose-designed score sheet. Three individual items (differential diagnosis [DDX], Support and Impressions [Impress]) showed significant improvement. The proportion of excellent scores for DDX increased by 50% from 40.8% to 61.6%. A χ(2) test for independence (with Yates continuity correction) indicated a significant association between the intervention and subsequent score (X(2) [1, n = 250] = 10.006, P < 0.001, phi -0.208). For Impress, a 48% increase in excellent scores was seen (39.2% to 58.4%). A χ(2) test for independence indicated a significant association between the intervention and subsequent score (X(2) [2, n = 250] = 11.249, P = 0.004, Cramer's V 0.212). The variable Support also improved (X(2) [2, n = 250] = 8.297, P = 0.012, Cramer's V 0.189) with the number of excellent scores increasing from 37.6% to 48.0%.ConclusionThe study demonstrated that documentation of clinical notes by interns can be enhanced by formal tuition.© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

      Pubmed     Full text   Copy Citation     Plaintext  

      Add institutional full text...

    Notes

     
    Knowledge, pearl, summary or comment to share?
    300 characters remaining
    help        
    You can also include formatting, links, images and footnotes in your notes
    • Simple formatting can be added to notes, such as *italics*, _underline_ or **bold**.
    • Superscript can be denoted by <sup>text</sup> and subscript <sub>text</sub>.
    • Numbered or bulleted lists can be created using either numbered lines 1. 2. 3., hyphens - or asterisks *.
    • Links can be included with: [my link to pubmed](http://pubmed.com)
    • Images can be included with: ![alt text](https://bestmedicaljournal.com/study_graph.jpg "Image Title Text")
    • For footnotes use [^1](This is a footnote.) inline.
    • Or use an inline reference [^1] to refer to a longer footnote elseweher in the document [^1]: This is a long footnote..

    hide…