Lost in translation: Unveiling medical students' untold errors of medical history documentation

IF 1.2 Q4 MEDICINE, RESEARCH & EXPERIMENTAL Clinical Teacher Pub Date : 2024-03-03 DOI:10.1111/tct.13749

Silvan Lange, Nils Krüger, Maximilian Warm, Johanna Buechel, Orsolya Genzel-Boroviczény, Martin R. Fischer, Konstantinos Dimitriadis

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Abstract

Objective

The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting.

Methods

In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness.

Results

Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category personal details overlapped with 94.2% between students' report and ground truth in contrast to the main category with the highest discrepancy, allergy, with 41.1% overlap. Pertinent negative items and non-numerical quantifications were often missed.

Conclusions

Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.

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翻译中的迷失：揭开医学生在病史记录中不可告人的错误。

目的：准确记录病史询问是医学教育的一个重要目标。由于学生的病史询问记录大多分散在病房中，因此缺乏对记录质量的系统评估。因此，我们在标准化环境中评估了学生病史报告中遗漏细节的程度：在这项前瞻性观察研究中，380 名学生中有 123 名（32.4%）参加了有关病史采集和记录的客观结构化临床考试（OSCE）。在访谈和九个演绎选择的主要类别的基础上，通过总结性定性内容分析建立了一个分类系统。笔录（被定义为基本事实）和学生报告中的项目被贴上标签并归入正确的子类别。将基本事实和学生报告进行比较，以量化学生文档的完整性：除了九个演绎选出的主要类别外，还定义了 61 个子类别。在 123 份访谈记录（基本事实）中共标注了 8943 个项目，而在学生报告中标注了 5870 个项目（与基本事实相比，学生报告的完整性为 65.6%）。学生报告中的主要个人资料类别与基本事实的重合率为 94.2%，而差异最大的主要类别--过敏--的重合率为 41.1%。重要的负面项目和非数字量化常常被遗漏：结论：医学生的病史访谈记录不完整。因此，准确记录病史应作为医学教育的一个重要目标。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Clinical Teacher MEDICINE, RESEARCH & EXPERIMENTAL-

CiteScore

2.90

自引率

5.60%

发文量

113

期刊介绍： The Clinical Teacher has been designed with the active, practising clinician in mind. It aims to provide a digest of current research, practice and thinking in medical education presented in a readable, stimulating and practical style. The journal includes sections for reviews of the literature relating to clinical teaching bringing authoritative views on the latest thinking about modern teaching. There are also sections on specific teaching approaches, a digest of the latest research published in Medical Education and other teaching journals, reports of initiatives and advances in thinking and practical teaching from around the world, and expert community and discussion on challenging and controversial issues in today"s clinical education.