Journal Club

Szauter, Karen M.; Ainsworth, Michael A.; Holden, Mark D.; Mercado, Anita C.; Do Students Do What they Write and Write What they Do? Academic Medicine October 2006. 81:10

Reviewed by Sandy Sanguino, Northwestern University

Written documentation of the patient encounter is an essential clinical skill. Many clerkships require students to submit their write-ups of their clinical encounters. One assumes that the data in the write-up is accurate and represents what actually took place in the student-patient interaction. There have been limited studies that have compared information obtained during the patient encounter and the corresponding notes.

This study was designed to provide a direct comparison between the student interaction with the patient and the subsequent note. This study focused on the physical examination (PE). The goal was to directly compare the physical exam maneuvers that were performed and the documentation of the PE in the patient note.

Information obtained from the senior medical student standardized patient-based clinical skills assessment at the University of Texas- Galveston was used for this study. For this study, three standardized-patient based scenarios were selected. Each encounter was video-recorded. For each of these encounters students were instructed to perform a focused medical interview and physical examination. Following the encounter, students were given 10 minutes to complete a patient note. The principle author reviewed each patient encounter-note pair along with one other investigator. The reviewers watched the PE portion of the encounter. Details of all PE maneuvers performed were transcribed then compared with the student's description of the PE in the corresponding note. There were five scoring categories: 1) all PE maneuvers recorded correctly 2) PE maneuver performed but not recorded 3) PE maneuver not performed but recorded 4) PE maneuver performed incorrectly 5) inaccurate documentation (inclusion of an abnormal physical exam finding that was not present. Reviews were done independently and scoring categories were compared. If the categories were different, transcribed details of the encounter were compared and consensus was reached through discussion.

A total of 207 encounter-note pairs were reviewed. 96% revealed some sort of mismatch between students did during the PE and what students recorded during the note. The most concerning things the authors found was that the majority of notes included documentation of findings from maneuvers that were either not performed during the PE or performed incorrectly such that the information could not have been reliably obtained. Of the 207 encounter-note pairs reviewed 82% were found to include information from exam maneuvers not performed or performed incorrectly. Documentation of PE abnormalities that were not actually present included findings relevant to the case content most of the time.

The limitations of this study include the restricted sample size and the setting from which the data were obtained, which may limit the generalizability of this study.

This study has several implications. It is essential that physical exam skills be reinforced during clinical training. Students also need to be able to correctly identify and document physical exam findings. Equally important is that students need to be reminded of the importance of the medical record and of the student's responsibility to document only what occurs during the patient encounter. This will become even more important as the use of the electronic medical record becomes more widespread.

(Editorial comment: Despite repeated pleas to record only what they find, students far too often record what they should find or what others find. It may be the fear of "missing" something or the potential "penalty" for an incomplete record drives this phenomena but this study raises interesting issues about professionalism in medical school. Bill Raszka)