Correlation of student performance on clerkship with quality of medical chart documentation in a simulation setting.
Correlation of student performance on clerkship with quality of medical chart documentation in a simulation setting.
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模拟环境中实习学生表现与病历记录质量的相关性。
DOI：
10.1371/journal.pone.0248569
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发表时间：
2021
期刊：
影响因子：
3.7
通讯作者：
Kawata R
中科院分区：
文献类型：
--
作者：
Komasawa N;Terasaki F;Nakano T;Kawata R
医疗图表文件是在临床见习（CC）获得的基本技能。然而，作为客观结构化临床检查（OSCE）的一个组成部分的医疗图表书写模拟的效用还没有得到充分的评价。在这项研究中，医疗图表文件在几个临床模拟设置进行了欧安组织的一部分，并与CC性能的相关性进行了评估。我们创建了一个临床情况的视频和图像，涉及获取知情同意书，心肺复苏术，并在急诊室的诊断成像，并评估医学生的医疗图表文件的性能作为欧安组织的一部分。使用原始检查表（0-10分）进行评价。我们还分析了120名医学生的病历记录OSCE分数与CC表现之间的相关性，这些医学生在2019年作为5年级学生进行了CC，并在2020年作为6年级学生参加了后CC OSCE。在OSCE的组成部分中，获得知情同意和复苏的评分与CC性能显着相关（P<0.001）。与此相反，诊断影像学评分显示与CC性能呈轻微正相关，但不显著（P = 0.107）。OSCE总分与CC表现显著相关（P<0.001）。我们进行了相关性分析的CC性能和医疗图表文件的质量在模拟设置。我们的研究结果表明，医疗图表文件可以在欧安组织的一个可能的替代组成部分。
Medical chart documentation is an essential skill acquired in a clinical clerkship (CC). However, the utility of medical chart writing simulations as a component of the objective structured clinical examination (OSCE) has not been sufficiently evaluated. In this study, medical chart documentation in several clinical simulation settings was performed as part of the OSCE, and its correlation with CC performance was evaluated. We created a clinical situation video and images involving the acquisition of informed consent, cardiopulmonary resuscitation, and diagnostic imaging in the emergency department, and assessed medical chart documentation performance by medical students as part of the OSCE. Evaluations were conducted utilizing original checklist (0–10 point). We also analyzed the correlation between medical chart documentation OSCE scores and CC performance of 120 medical students who performed their CC in 2019 as 5th year students and took the Post-CC OSCE in 2020 as 6th year students. Of the OSCE components, scores for the acquisition of informed consent and resuscitation showed significant correlations with CC performance (P<0.001 for each). In contrast, scores for diagnostic imaging showed a slightly positive, but non-significant, correlation with CC performance (P = 0.107). Overall scores for OSCE showed a significant correlation with CC performance (P<0.001). We conducted a correlation analysis of CC performance and the quality of medical chart documentation in a simulation setting. Our results suggest that medical chart documentation can be one possible alternative component in the OSCE.
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