COMSEP 2008 Atlanta Meeting
PEDIATRIC JUNIOR CLERKSHIP STUDENTS: DO THEY DO WHAT THEY DOCUMENT? DO THEY DOCUMENT WHAT THEY DO?
M Broussard, D Rasmussen, PF Bass.
Louisiana State University Health Sciences Center, Shreveport, LA
Objectives: 1. Do inconsistencies exist between the physical examination (PE) maneuvers and documentation of these maneuvers as documented by junior medical students? 2. Do documentation errors decrease as students progress through the clinical 3rd year?
Methods: Pediatric Junior Clerkship students in our outpatient clinic were recorded performing examinations on patients 5 years old and younger with appropriate consent. Each videoed encounter was reviewed independently and results recorded on a PE checklist. PE elements performed incorrectly were noted on the form. A separate investigator reviewed copies of clinic notes for each patient encounter; results were recorded on a separate checklist. The checklists were compared; discrepancies between performed PE skills and the corresponding documentation were recorded.
Results: Eighteen student-patient encounters were recorded and reviewed. All encounters were performed by junior medical students (n=13) with approximately the same amount of training (< 6 months clinical experience). 227 PE maneuvers were performed; 71% were documented. 211 items were documented in the corresponding clinic notes, 23% were not clearly performed on the video. The most common elements documented but not performed were eye and neck examinations. The video reviewer did not see any PE elements performed incorrectly. Since all students have approximately the same amount of clinical experience, no trends related to this could be identified.
Conclusions: No encounters were completely and accurately documented. Limitations include a single-institution study with a small number of encounters. Data are still being collected.