Assessing medical student documentation using simulated charts in emergency medicine
Assessing medical student documentation using simulated charts in emergency medicine
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DOI：
10.1186/s12909-018-1314-z
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发表时间：
2018-08-28
影响因子：
3.6
通讯作者：
Lotfipour, Shahram
中科院分区：
文献类型：
--
作者：
Hoonpongsimanont, Wirachin;Velarde, Irene;Lotfipour, Shahram
背景资料：1995年卫生保健财务管理局（HCFA）的指导方针指出，供应商可能只使用系统和过去的医疗，家庭，社会历史的审查，在学生的文件计费的目的，因此，许多供应商认为学生的文件作为一个无关的步骤，并选择不允许医学生记录病人的访问。这种工作流程对医学生的文档技能教育产生了负面影响。虽然对学生的文件技能的负面影响是显而易见的，不足的领域是未知的。了解赤字领域将有利于未来的实习医生准备适当的文件。我们的目的是评估领域的赤字在第四年医学生的文件根据HCFA billing guidelines.Methods：我们进行了一项前瞻性研究，第四年医学生的模拟图表文件在美国医学院从2014年5月至2015年5月。我们评估学生的模拟图表从一个在线学习工具，使用模拟的情况下，根据HCFA指南的完整性和分析数据使用描述statistics.Results：我们发现，98.9%（n = 90）的图表被下调编码。其中33.0%（n = 30）的患者目前病史不完整，90.1%（n = 82）的患者系统回顾不完整，73.6%（n = 67）的患者既往病史、家族史、社会史不完整，88.8%（n = 80）的患者体格检查不完整。新课程应包括计费指南信息，并根据敏锐度强调图表的完整性。
Background: The 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.Methods: We 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.Results: We 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.Conclusion: New curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.