BACKGROUND: Patient notes are used for a variety of purposes in health care. Medical students are taught the structure of patient notes early in training. Review of patient notes are then used to assess synthesis and integration of patient information. It is critical that the information in the note accurately and completely represents the student-patient encounter. METHOD: The authors reviewed videotapes of students in three standardized-patient based scenarios and compared what occurred during the physical examination with the subsequent documentation in the patient note. RESULTS: In all, 207 encounter-note pairs were reviewed. Only 8 (4%) of the notes completely and accurately represented what occurred during the encounter. Problems with underdocumentation, overdocumentation, and inaccurate documentation of physical findings were seen for all three patient scenarios. CONCLUSIONS: These findings highlight the need to teach and assess both data gathering skills and written documentation of findings in medical training.
BACKGROUND:Patient notes are used for a variety of purposes in health care. Medical students are taught the structure of patient notes early in training. Review of patient notes are then used to assess synthesis and integration of patient information. It is critical that the information in the note accurately and completely represents the student-patient encounter. METHOD: The authors reviewed videotapes of students in three standardized-patient based scenarios and compared what occurred during the physical examination with the subsequent documentation in the patient note. RESULTS: In all, 207 encounter-note pairs were reviewed. Only 8 (4%) of the notes completely and accurately represented what occurred during the encounter. Problems with underdocumentation, overdocumentation, and inaccurate documentation of physical findings were seen for all three patient scenarios. CONCLUSIONS: These findings highlight the need to teach and assess both data gathering skills and written documentation of findings in medical training.