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Are students less likely to report pertinent negatives in post-encounter notes?
Anne Walling1, Scott E Moser, Gretchen Dickson
1Department of Family and Community Medicine, University of Kansas School of Medicine-Wichita, KS 67214, USA. awalling@kumc.edu
Family Medicine
|January 14, 2012
Summary
Medical students under-report crucial negative findings in post-encounter notes (PENs) more often than positive ones. This omission impacts patient care and medicolegal outcomes, highlighting a gap in clinical documentation.
Area of Science:
- Medical Education
- Clinical Documentation
- Patient Safety
Background:
- Incomplete post-encounter notes (PENs) by students are a significant issue, potentially leading to adverse patient care and medicolegal consequences.
- A substantial amount of important medical history information, estimated at 30%, is believed to be under-reported in PENs.
Purpose of the Study:
- To investigate the hypothesis that pertinent negative findings are more likely to be under-reported in PENs compared to pertinent positive findings.
- To compare the reporting rates of positive and negative items in clinical notes generated by medical students.
Main Methods:
- A clinical skills assessment (CSA) involving two cases was administered to 55 third-year medical students.
- Students' ability to elicit information was assessed using standardized patient (SP) checklists.
- The reporting of pertinent positive and negative items in the students' post-encounter notes (PENs) was scored.
Main Results:
- Students successfully obtained 87% of both positive and negative items from standardized patients.
- However, PEN scoring revealed significant differences in reporting rates: 75% for positive items versus 52% for negative items.
- These disparities were consistent across both assessed cases.
Conclusions:
- Medical students can elicit pertinent negative information during patient encounters.
- Despite their importance, negative findings are significantly more likely to be omitted from clinical notes than positive findings.
- This under-reporting of crucial negative information in PENs poses a risk to patient care and medical-legal outcomes.
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