ArticleBMC medical education2018
Assessing medical student documentation using simulated charts in emergency medicine.
Article in BMC medical education, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
6 citing papers in PubMed, 11 citations in OpenAlex.
- Documentation from trained medical students has a low rate of relative downcoding for emergency medicine encounters.AEM education and training · 2022Article
- Improving Medical Student Inpatient Documentation Through Feedback Using a Note Assessment Tool.Cureus · 2022Article
- How Pharmaceuticals Mask Health and Social Inequity.AMA journal of ethics · 2021Article
- Correlation of student performance on clerkship with quality of medical chart documentation in a simulation setting.PloS one · 2021Article
- Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship.MedEdPORTAL : the journal of teaching and learning resources · 2021Article
- Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department.AEM education and training · 2019Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe 1995 Health Care Financing Administration (HCFA) guidelines stated that providers may only use the review of systems and past medical, family, social history in student documentation for billing purposes; therefore, many providers viewed the student documentation as an extraneous step and chose not to allow medical students to document patient visits. This workflow negatively affected medical student education in documentation skills. Although the negative impact on students' documentation skills is obvious, areas of deficits are unknown. Understanding the area of deficits will benefit future curriculums to prepare prospective resident physicians for proper documentation. We aimed to assess areas of deficits in documentation of fourth-year medical students according to HCFA billing guidelines.
methodsWe conducted a prospective study of fourth-year medical students' simulated chart documentations at a United States medical school from May 2014 to May 2015. We evaluated students' simulated charts from an online learning tool using simulated cases for completeness according to HCFA guidelines and analyzed data using descriptive statistics.
resultsWe found that 98.9% (n = 90) of the charts were downcoded. Of these charts, 33.0% (n = 30) had incomplete history of present illness, 90.1% (n = 82) had incomplete review of systems, 73.6% (n = 67) had incomplete past medical, family, social history and 88.8% (n = 80) had incomplete physical exams.
conclusionNew curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.