ArticleInternational journal of medical education2017
Assessment of junior doctors' admission notes: do they follow what they learn?
Article in International journal of medical education, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 4 papers.
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Who cites it
4 citing papers in PubMed.
- Data completeness and consistency in individual medical records of institutional births: retrospective crossectional study from Northwest Ethiopia, 2022.BMC health services research · 2023Article
- The midwives' experiences of the use of obstetric triage and obstetric triage tool during labour in Bojanala district.Health SA = SA Gesondheid · 2022Article
- Impact of a medical admissions proforma on the quality of medical admission documentation in a general acute hospital in Ireland.Irish journal of medical science · 2020Article
- International Standards for Neurological Classification of Spinal Cord Injury: factors influencing the frequency, completion and accuracy of documentation of neurology for patients with traumatic spinal cord injuries.European journal of orthopaedic surgery & traumatology : orthopedie traumatologie · 2019Article
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Authors and funding
8 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesTo assess the completeness of history-taking and physical-examination notes of junior doctors at King Abdulaziz University Hospital per the approach they learned in medical school.
methodsIn this retrospective study, we reviewed 860 admission notes written by 269 junior doctors (interns and residents) in an academic tertiary-care medical centre in Jeddah, Saudi Arabia, over a two-month period. Notes were evaluated for completeness using a checklist developed with reference to relevant medical textbooks. The checklist included 32 items related to history-taking and physical examination. Based on the review of the notes, checklist items were evaluated as complete, incomplete, not present, or not applicable according to set criteria. Data were analysed and summarised for information on the frequency and relative frequency of these types.
resultsThe history items varied in completeness. At the high end, asking about chief complaint and duration, associated symptoms, aggravating and relieving factors, and conducting systemic review were marked 'complete' in 74.2%, 81.7%, 80.4%, and 79.7% of notes, respectively. At the low end, asking about previous episodes, allergies, medications, and family history were complete in 5.3%, 1.9%, 4.8%, and 2.9% of notes, respectively. All physical examination items were poorly documented, especially breast examination, which was 'not present' in 95.8% of the notes.
conclusionsJunior doctors' history and physical-examination notes are often incomplete and do not follow the approach taught in medical school. The reasons for this must be studied via focus-group discussions with junior doctors.
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