Assessing the quality of electronic medical records as a platform for resident education

Abstract Background Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition...

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Autores principales:	Hsuan Hung, Ling-Ling Kueh, Chin-Chung Tseng, Han-Wei Huang, Shu-Yen Wang, Yu-Ning Hu, Pao-Yen Lin, Jiun-Ling Wang, Po-Fan Chen, Ching-Chuan Liu, Jun-Neng Roan
Formato:	article
Lenguaje:	EN
Publicado:	BMC 2021
Materias:	Note quality Quality improvement Resident education Special aspects of education LC8-6691 Medicine R
Acceso en línea:	https://doaj.org/article/692de910dbb049f7aa58681e84b9eec3
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spelling	oai:doaj.org-article:692de910dbb049f7aa58681e84b9eec32021-11-14T12:43:09ZAssessing the quality of electronic medical records as a platform for resident education10.1186/s12909-021-03011-01472-6920https://doaj.org/article/692de910dbb049f7aa58681e84b9eec32021-11-01T00:00:00Zhttps://doi.org/10.1186/s12909-021-03011-0https://doaj.org/toc/1472-6920Abstract Background Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants’ medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications. Methods The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA). Results Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92). Conclusions This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.Hsuan HungLing-Ling KuehChin-Chung TsengHan-Wei HuangShu-Yen WangYu-Ning HuPao-Yen LinJiun-Ling WangPo-Fan ChenChing-Chuan LiuJun-Neng RoanBMCarticleNote qualityQuality improvementResident educationSpecial aspects of educationLC8-6691MedicineRENBMC Medical Education, Vol 21, Iss 1, Pp 1-8 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	Note quality Quality improvement Resident education Special aspects of education LC8-6691 Medicine R
spellingShingle	Note quality Quality improvement Resident education Special aspects of education LC8-6691 Medicine R Hsuan Hung Ling-Ling Kueh Chin-Chung Tseng Han-Wei Huang Shu-Yen Wang Yu-Ning Hu Pao-Yen Lin Jiun-Ling Wang Po-Fan Chen Ching-Chuan Liu Jun-Neng Roan Assessing the quality of electronic medical records as a platform for resident education
description	Abstract Background Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants’ medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications. Methods The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA). Results Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92). Conclusions This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.
format	article
author	Hsuan Hung Ling-Ling Kueh Chin-Chung Tseng Han-Wei Huang Shu-Yen Wang Yu-Ning Hu Pao-Yen Lin Jiun-Ling Wang Po-Fan Chen Ching-Chuan Liu Jun-Neng Roan
author_facet	Hsuan Hung Ling-Ling Kueh Chin-Chung Tseng Han-Wei Huang Shu-Yen Wang Yu-Ning Hu Pao-Yen Lin Jiun-Ling Wang Po-Fan Chen Ching-Chuan Liu Jun-Neng Roan
author_sort	Hsuan Hung
title	Assessing the quality of electronic medical records as a platform for resident education
title_short	Assessing the quality of electronic medical records as a platform for resident education
title_full	Assessing the quality of electronic medical records as a platform for resident education
title_fullStr	Assessing the quality of electronic medical records as a platform for resident education
title_full_unstemmed	Assessing the quality of electronic medical records as a platform for resident education
title_sort	assessing the quality of electronic medical records as a platform for resident education
publisher	BMC
publishDate	2021
url	https://doaj.org/article/692de910dbb049f7aa58681e84b9eec3
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Assessing the quality of electronic medical records as a platform for resident education

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