BackgroundThe 1995 Health Care Financing Administration (HCFA) guidelines stated that providers may only use the review of systems and past medical, family, social history in student documentation for billing purposes; therefore, many providers viewed the student documentation as an extraneous step and chose not to allow medical students to document patient visits. This workflow negatively affected medical student education in documentation skills. Although the negative impact on students’ documentation skills is obvious, areas of deficits are unknown. Understanding the area of deficits will benefit future curriculums to prepare prospective resident physicians for proper documentation. We aimed to assess areas of deficits in documentation of fourth-year medical students according to HCFA billing guidelines.MethodsWe conducted a prospective study of fourth-year medical students’ simulated chart documentations at a United States medical school from May 2014 to May 2015. We evaluated students’ simulated charts from an online learning tool using simulated cases for completeness according to HCFA guidelines and analyzed data using descriptive statistics.ResultsWe found that 98.9% (n = 90) of the charts were downcoded. Of these charts, 33.0% (n = 30) had incomplete history of present illness, 90.1% (n = 82) had incomplete review of systems, 73.6% (n = 67) had incomplete past medical, family, social history and 88.8% (n = 80) had incomplete physical exams.ConclusionNew curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.

PurposeProviding feedback to students in the emergency department during their emergency medicine clerkship can be challenging due to time constraints, the logistics of direct observation, and limitations of privacy. The authors aimed to evaluate the effectiveness of first-person video, captured via Google Glass™, to enhance feedback quality in medical student education.Material and methodsAs a clerkship requirement, students asked patients and attending physicians to wear the Google Glass™ device to record patient encounters and patient presentations, respectively. Afterwards, students reviewed the recordings with faculty, who provided formative and summative feedback, during a private, one-on-one session. We introduced the intervention to 45, fourth-year medical students who completed their mandatory emergency medicine clerkships at a United States medical school during the 2015–2016 academic year.ResultsStudents assessed their performances before and after the review sessions using standardized medical school evaluation forms. We compared students’ self-assessment scores to faculty assessment scores in 14 categories using descriptive statistics and symmetric tests. The overall mean scores, for each of the 14 categories, ranged between 3 and 4 (out of 5) for the self-assessment forms. When evaluating the propensity of self-assessment scores toward the faculty assessment scores, we found no significant changes in all 14 categories. Although not statistically significant, one fifth of students changed perspectives of their clinical skills (history taking, performing physical exams, presenting cases, and developing differential diagnoses and plans) toward faculty assessments after reviewing the video recordings.ConclusionFirst-person video recording still initiated the feedback process, allocated specific time and space for feedback, and possibly substituted for the direct observation procedure. Additional studies, with different outcomes and larger sample sizes, are needed to understand the effectiveness of first-person video in improving feedback quality.

Methods: Six hundred clinical records of student visits to the ED in 6 academic years from 2009-10 to 2014-15 were randomly selected for chart review by 2 independent reviewers to identify visits with alcohol intoxication. Results were then compared with ICD-9 diagnostic codes indicating alcohol intoxication (30500, 30502, and 3030) in the hospital discharge database. Sensitivity, specificity, positive predictive and negative predictive values were calculated to evaluate the validity of diagnostic codes using the chart review as the "gold standard."Results: Over the study period, there were 9616 student visits to ED. Overall prevalence of alcohol intoxication was 10.4% based on ICD-9 diagnostic codes. Of the review sample of 600 records, the use of ICD-9 diagnostic codes in patient medical records identified 64 visits (10.6%) with alcohol intoxication, while the chart review identified 96 visits (16%) with alcohol intoxication. Sensitivity was 65%, indicating that ICD-9 diagnostic codes only captured 65% of the total ED visits with alcohol intoxication in the review sample. The specificity, positive predictive value, negative predictive value, and accuracy were 99%, 94%, 94%, and 94%, respectively (Table 1). There were 41 visits which involved both alcohol intoxication and injury or trauma, of which alcohol intoxication diagnostic codes were provided in only 18 visits (44%).Conclusions: Although code-based recording of student ED visits due to alcohol intoxication had a high level of accuracy, over one third of ED visits due to alcohol intoxication were not captured by diagnostic codes. In particular, when the visit also involved injury or trauma, only less than half of visits with alcohol intoxication were given a diagnostic code for this condition. Code-based measurement appears to severely underestimate the true burden of alcohol intoxication in the ED associated with student visits. There is a strong need to improve emergency physician coding of alcohol intoxication so that ED electronic medical records can serve as a reliable data source to evaluate the burden of alcohol intoxication in the hospital emergency setting.