Evaluation of the Congruence Between Students' Postencounter Notes and Standardized Patients' Checklists in a Clinical Skills Examination

• Published in: Teaching and learning in medicine 2008-01, Vol.20 (1), p.31-36
• Main Authors: Worzala, Katherine, Rattner, Susan, Boulet, John, Majdan, Joseph, Berg, Dale, Robeson, Mary, Veloski, J.
• Format: Article
• Language: English
• Subjects: Adult; Clinical Clerkship - standards; Clinical Competence - standards; Curriculum; Education, Medical, Undergraduate - standards; Female; Humans; Male; Medical History Taking - methods; Patient Education as Topic - standards; Pennsylvania; Physical Education and Training - methods; Reproducibility of Results; Students, Medical
• ISSN: 1040-1334; 1532-8015
• DOI: 10.1080/10401330701798253

Background and Purpose: Questions remain about the congruence between students' written notes and checklists as summaries of encounters. Methods: Students examined standardized patients and summarized findings in postencounter notes. The patients completed checklists. A physician read the students' notes and completed parallel checklists to document the history and physical items performed. Rates of under- and overdocumentation were calculated. Results: Students documented findings for 71% of items performed-an underdocumentation rate of 29%. Approximately 94% of their documented findings were consistent with what they had done. Their rate of overdocumentation was 6%, in which they documented findings inconsistent with the checklists. About half the students had no instances of overdocumentation. Conclusion: Students' rate of underdocumentation was comparable to experienced clinicians. Although their overdocumentation rate was low overall, it was high for a few students. Evaluation of the congruence between checklists and postencounter notes provides useful information and informs checklist development.