Marlene M. Broussard, MD, Pat F. Bass, MD, MPH, Joseph A. Bocchini, MD, LSUHSC-Shreveport, Shreveport, LA
PURPOSE: The primary purpose of this study is to determine if inconsistencies exist between the examination maneuvers and documentation of these maneuvers as documented by junior medical students. An additional purpose is to see whether documentation errors decrease as students progress throughout the clinical 3rd year. METHODS: Funding was secured through a COMSEP educational grant. IRB approval was obtained. Junior medical students on the outpatient clinic rotation of the Pediatric Clerkship were recorded performing examinations on patients younger than 5 years old with appropriate consent. Each videoed encounter was reviewed independently and results were recorded on a standard physical exam checklist. Exam elements performed incorrectly were also noted on the form. A separate investigator reviewed copies of clinic notes for each patient encounter and recorded results from the clinic note on the checklist. Both checklists were compared to determine if any discrepancies between performed physical examination skills and the corresponding documentation existed. RESULTS: Twenty-five student-patient encounters have been recorded and reviewed. All encounters have been performed by junior medical students (n=20) with varying amounts of clinical training. On the 25 videos, 296 physical exam maneuvers were performed; only 73% were documented. There were 302 items documented in the 25 corresponding clinic notes, 28% of which 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 physical exam elements that were incorrectly performed. 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 to determine whether documentation errors decrease as students progress throughout the clinical 3rd year.