The medical record and the medical interview: an evaluation of student case histories

This study assessed the results of a second-year family medicine course designed to improve student abilities in writing complete assessments and plans from interviews with standardized patients. Sixty-six students attended lectures on the patient's perception of the symptoms of the major causes of death, learned techniques of medical interviewing, saw a model interview by their tutor, received model faculty histories based on American Board of Family Practice Office Record Review Criteria, and received critiques of their own histories. Students in the highest decile recorded twice as much information as those in the lowest decile and recorded as many history items as the faculty member who recorded the most history items. The faculty, however, recorded a more complete list of diagnoses, differential diagnoses, and investigations. Students in the lowest decile recorded the least information and the least number of assessments and plans and did not respond to written critiques. Students in the lowest decile could improve if they were identified early in the course and worked intensively with role models.