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Clinical procedures performed by emergency medicine resident physicians: a computer-based model for documentation
1Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina 27858-4354.
The Journal of Emergency Medicine
|May 1, 1991
Summary
A new microcomputer system effectively tracked clinical procedures performed by emergency medicine residents. High compliance (84%) and detailed data on procedures like resuscitation and intubation demonstrate its utility for medical education and credentialing.
Area of Science:
- Medical Education
- Health Informatics
- Emergency Medicine
Background:
- Accurate documentation of clinical procedures is crucial for resident training and evaluation.
- Traditional methods often lack efficiency and completeness in capturing procedural data.
Purpose of the Study:
- To develop and evaluate a microcomputer-based system for recording clinical procedures performed by resident physicians.
- To assess the compliance rate and types of procedures documented using the new system.
Main Methods:
- Residents used precoded books to record procedures after completion.
- Clerical staff transferred data from books to a database program.
- The system was utilized by 17 emergency medicine residents over a one-year period.
Main Results:
- A compliance rate of 84% was achieved, with 1,857 procedures recorded.
- Most frequent procedures included resuscitation (20%), orotracheal intubation (12%), and central vein cannulation (12%).
- Other common procedures were lumbar puncture (7%) and diagnostic peritoneal lavage (5%).
Conclusions:
- The microcomputer-based system demonstrated high resident acceptance and compliance.
- This tool allows for effective monitoring of resident procedural experience and curriculum development.
- The system provides valuable data for review organizations and credentials committees.