Related Experiment Video
Updated: Jul 1, 2026
A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
Development and validation of standardized clinical summary format
I C Anochie1, K E O Nkanginieme, N Eke
1Department of Paediatrics and Child Health, University of Port Harcourt. anochieify@hotmail.com
Background:
The use of a structured guideline in medical education to reach a diagnosis provides accurate information which is relatively free from bias. The purpose of this paper is to assess the performance of medical students using unstructured and structured format in case summary.
Methods:
One hundred and sixty- nine medical students in Part III MB; BS Programme in the University of Port Harcourt were studied. There were 83 students in Paediatics [SP] and 86 students in Obstetrics and Gynaecology [SOG] postings. The students had video recorded presentation of three clinical cases comprising of two paediatrics [PC1&PC2] and one surgical case [SC3]. The summary for the first case [PC1] was done using an unstructured format, while the second case [PC2] was done with both unstructured PC2a and structured PC2b format. The Surgical case [SC3] was done using only the structured format. The discrete pieces of important information in each case were quantified and scored by trained assessors. PC1and SC3 had a total of 16 points each while PC2 had a total of 24 points.
Result:
The pre-exposed SOG students scored significantly higher than none-exposed SPG students in PC1 and SC3; P<0.05. In PC2 75.1% students scored above 12 points using structured summary format compared to 38.5% students with unstructured format , P<0.05. The students had significantly higher score using structured format in SC3 than PC1.
Conclusion:
The use of structured summary format enabled better case summary than unstructured format, and it's transferable across different departments.
Related Concept Videos
01:31Discharge Summary Forms
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
01:17Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
01:28Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
01:23Methods of Documentation V: CBE
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
01:27Nursing Clinical Information System
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
01:26Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information: