Assessment of junior doctors’ admission notes: do they follow what they learn?

Abstract

ObjectivesTo assess the completeness of history-taking and physical-examination notes of junior doctors at King Abdulaziz University Hospital per the approach they learned in medical school. MethodsIn this retrospective study, we reviewed 860 admission notes written by 269 junior doctors (interns and residents) in an academic tertiary-care medical centre in Jeddah, Saudi Arabia, over a two-month period. Notes were evaluated for completeness using a checklist developed with reference to relevant medical textbooks. The checklist included 32 items related to history-taking and physical examination. Based on the review of the notes, checklist items were evaluated as complete, incomplete, not present, or not applicable according to set criteria. Data were analysed and summarised for information on the frequency and relative frequency of these types. ResultsThe history items varied in completeness. At the high end, asking about chief complaint and duration, associated symptoms, aggravating and relieving factors, and conducting systemic review were marked ‘complete’ in 74.2%, 81.7%, 80.4%, and 79.7% of notes, respectively. At the low end, asking about previous episodes, allergies, medications, and family history were complete in 5.3%, 1.9%, 4.8%, and 2.9% of notes, respectively. All physical examination items were poorly documented, especially breast examination, which was ‘not present’ in 95.8% of the notes. ConclusionsJunior doctors’ history and physical-examination notes are often incomplete and do not follow the approach taught in medical school. The reasons for this must be studied via focus-group discussions with junior doctors.

International Standards for Neurological Classification of Spinal Cord Injury: factors influencing the frequency, completion and accuracy of documentation of neurology for patients with traumatic spinal cord injuries

“…The inadequacies and inaccuracy in documentation found in the present study may be a consequence of lack of the essential knowledge or skills required for ISNCSCI documentation, negligence or lack of understanding of the importance of adequate documentation [3, 12–17]. The low completion and accuracy rates raise some questions on whether ISNCSCI should be used at all in an acute care clinical environment, if no quality control is installed and no structured ISNCSCI training is mandatory.…”

“…In this period, documentation is usually performed by junior doctors who have variable training on neurological assessment. Several studies have shown that medical records by junior doctors were incomplete and lacked essential data on physical examination of the patients [12–15]. Previous studies conducted in the artificial settings of ISNCSCI training courses and clinical trials have revealed challenges in achieving accuracy in the completion of ISNCSCI charts [2, 3, 16, 17].…”

Assessment of the documentation completeness level of the medical records in Basrah General Hospital

“…In a retrospective study involved reviewing completeness of 860 admission notes in Jeddah, Saudi Arabia, poor documentation of the admission notes was reported in 95% of the medical records specially those including the physical examination notes on admission of the patients. [13] A study done in Korea in 2014 to assess the completeness of medical records, only 27.4% of the records were found to be completely documented especially for items related to the patient's symptoms and examination . [14] Higher figures were revealed in our study especially in the surgical, medical and Gynecology/Obstetric departments.…”

Health Workers’ Documentation Process as a Prerequisite to the Integration of Patient Care at a Regional Referral Hospital in Uganda

“…Around half of the records documented an examination of the cardiovascular system, whereas other aspects of physical examination were minimally documented. Barnawi et al (2017), after their study that assessed the junior doctors' admission notes, state that the reasons for the grave omissions might be related to the perceptions that the details are unnecessary or time-wasting or the doctors may think that omitting the details may not affect the patient's care. Yet the omission has clinical implications, such as missed diagnoses, as a diagnosis may be made more easily using information obtained from a complete physical examination [31] [32] [33].…”

“…However, there could be other inevitable factors like lack of time caused by workover load and limited knowledge in the area of assessment and documentation skills. Similar institutional factors like lack of the appropriate diagnostic equipment might be one of the contributory factors to the incomplete records from the doctors [34].…”