Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital. (13th January 2015)

• Record Type: Journal Article
• Authors: Isoardi, Jonathon; Spencer, Lyndall; Sinnott, Michael; Eley, Robert
• Is Part Of: Emergency medicine Australasia. Volume 27:Number 1(2015:Feb.)
• Page Start: 6
• Page End: 10
• Publication Date: 2015-01-13
• Subjects: Emergency medicine -- Periodicals; Emergency medicine -- Australasia -- Periodicals; 616.025
• DOI: 10.1111/1742-6723.12343
• Languages: English
• ISSNs: 1742-6731

Abstract

<abstract abstract-type="main"> <title>Abstract</title> <sec id="emm12343-sec-0001" sec-type="section"> <title>Objectives</title> <p>This study's objective was to determine whether tuition in medical documentation enhanced the ability of emergency medicine interns to produce effective medical records.</p> </sec> <sec id="emm12343-sec-0002" sec-type="section"> <title>Methods</title> <p>The study adopted a case control design, using a retrospective document audit methodology, following an education intervention during the 'More Learning for Interns in Emergency' (MoLIE) programme. It was conducted in a tertiary hospital that supports five 10 week rotations of 12 interns each year (<italic>n</italic> = 60). Controls were drawn from records written in March 2012 and cases from March 2013. A total of 250 medical records written by interns were audited, 125 from each year.</p> </sec> <sec id="emm12343-sec-0003" sec-type="section"> <title>Results</title> <p>Three categories of documentation were investigated: patient characteristics, clinical impressions and management plan using a purpose‐designed score sheet. Three individual items (differential diagnosis [DDX], Support and Impressions [Impress]) showed significant improvement. The proportion of excellent scores for DDX increased by 50% from 40.8% to 61.6%. A χ<sup>2</sup> test for independence (with Yates continuity correction) indicated a significant association between the intervention and subsequent score (X<sup>2</sup>[1, <italic>n</italic> = 250] = 10.006, <italic>P</italic> < 0.001, phi −0.208). For Impress, a 48% increase in excellent scores was seen (39.2% to 58.4%). A χ<sup>2</sup> test for independence indicated a significant association between the intervention and subsequent score (X<sup>2</sup>[2, <italic>n</italic> = 250] = 11.249, <italic>P</italic> = 0.004, Cramer's V 0.212). The variable Support also improved (X<sup>2</sup>[2, <italic>n</italic> = 250] = 8.297, <italic>P</italic> = 0.012, Cramer's V 0.189) with the number of excellent scores increasing from 37.6% to 48.0%.</p> </sec> <sec id="emm12343-sec-0004" sec-type="section"> <title>Conclusion</title> <p>The study demonstrated that documentation of clinical notes by interns can be enhanced by formal tuition.</p> </sec> </abstract>