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Evaluation of the congruence between students' postencounter notes and standardized patients' checklists in a
Katherine Worzala1, Susan L Rattner, John R Boulet
1Clinical Skills Center, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA. Katherine.Worzala@jefferson.edu
Background And Purpose:
Questions remain about the congruence between students' written notes and checklists as summaries of encounters.
Methods:
Students examined standardized patients and summarized findings in postencounter notes. The patients completed checklists. A physician read the students' notes and completed parallel checklists to document the history and physical items performed. Rates of under- and overdocumentation were calculated.
Results:
Students documented findings for 71% of items performed - an underdocumentation rate of 29%. Approximately 94% of their documented findings were consistent with what they had done. Their rate of overdocumentation was 6%, in which they documented findings inconsistent with the checklists. About half the students had no instances of overdocumentation.
Conclusion:
Students' rate of underdocumentation was comparable to experienced clinicians. Although their overdocumentation rate was low overall, it was high for a few students. Evaluation of the congruence between checklists and postencounter notes provides useful information and informs checklist development.
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