Araştırma Makalesi
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Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations

Yıl 2023, Cilt: 15 Sayı: 2, 257 - 265, 22.06.2023
https://doi.org/10.18521/ktd.1259969

Öz

Objective: To determine the need for clinical record keeping education in undergraduate programs at our university.
Methods: Qualitative descriptive research method was used. To determine clinical record keeping education needs, interviews were conducted with 10 faculty members working at the Faculty of Medicine in the 2022-2023 academic year, using a semi-structured form. In addition, a 17-question survey was administered to elicit the needs of the students attending the Faculty of Medicine.
Results: A total of 102 students participated in the study. Eighty-two (80.4%) students reported not having received any education on clinical record keeping. For the questions scored on a seven-point Likert scale, related to how competent they considered themselves to be in clinical record keeping and how comfortable they felt while writing patient notes, the mean scores were calculated to be 3.89±1.66 and 3.55±1.74, respectively. Ninety-two (90.2%) students considered it necessary to take a course on how to keep clinical records. Ten faculty members participated in the interviews conducted using a semi-structured form. During these interviews, emerging themes concerning the quality of clinical records were the comprehensiveness and usefulness of these records, and the use of appropriate language. When the reasons for deficiencies in clinical record keeping were questioned, problems in the education system and a lack of education were prominent.
Conclusion: We identified the deficiencies and needs related to clinical record keeping in our faculty. Based on our results, we consider that the implementation of appropriate curricula and activities will increase the quality of clinical records.

Kaynakça

  • 1. Rowlands S, Coverdale S, Callen J. Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education. Health Inf Mana. 2016;45:99-106.
  • 2. Kuhn T, Basch P, Barr M, Yackel T. Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162:301-3.
  • 3. Haghighi MH, Dehghani M, Teshnizi SH, Mahmoodi H. Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. Health Inf Manag. 2014;43:35-42.
  • 4. Seo JH, Kong HH, Im SJ, Roh H, Kim DK, Bae HO, Oh YR. A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean J Med Educ. 2016;28:237-41.
  • 5. Yılmaz BK, Topcu H, Acar YA. Assessment of legal obligations of physicians from emergency physician perspective. Med Bull Sisli Etfal Hosp. 2017;51: 142-8
  • 6. Jackson T. Data quality: not selling ourselves short. Health Inf Manag. 2014;43:4-6.
  • 7. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust. 2008;188:506-9.
  • 8. Alromaihi D, Godfrey A, Dimoski T, Gunnels P, Scher E, Baker-Genaw K. Internal medicine residents' time study: paperwork versus patient care. J Grad Med Educ. 2011;3:550-3.
  • 9. Oxentenko AS, West CP, Popkave C, Weinberger SE, Kolars JC. Time spent on clinical documentation: a survey of internal medicine residents and program directors. Arch Intern Med. 2010;170:377-80.
  • 10. Friedman E, Sainte M, Fallar R. Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Acad Med. 2010;85:1440-4.
  • 11. Mezuniyet Öncesi Ulusal Çekirdek Eğitim Programı; 2020 [cited 2023 Jan 23]. Available from: https://www.yok.gov.tr/Documents/Kurumsal/egitim_ogretim_dairesi/Ulusal-cekirdek-egitimi-programlari/mezuniyet-oncesi-tip-egitimi-cekirdek-egitimi-programi.pdf
  • 12. Köse A, Köse B, Öncü MR, Tuğrul F. Bir devlet hastanesi acil servisine başvuran hastaların profili ve başvurunun uygunluğu. Gaziantep Medical Journal. 2011;17:57-62.
  • 13. Dönmez SS, Durak VA, Torun G, Köksal Ö, Aydın Ş. Acil Serviste Gerçekleştirilen Konsültasyon Sürecinin İncelenmesi. Uludağ Tıp Derg. 2017;43:23-8.
  • 14. Borkan J. Immersion-crystallization. In: Crabtree BF, Miller WL, editors. Doing qualitative research (Research Methods for Primary Care) Newbury Park: Sage Publications; 1999. p. 179-84.
  • 15. Lai J, Tillman D. Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship. MedEdPORTAL. 2021;17:11194.
  • 16. Dawson B, Carter K, Brewer K, Lawson L. Chart smart: a need for documentation and billing education among emergency medicine residents? West J Emerg Med. 2010;11:116-9.
  • 17. Fakhry SM, Robinson L, Hendershot K, Reines HD. Surgical residents' knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg. 2007;194:263-7.
  • 18. Malekpour N, Noori A, SamadPour Amlashi T. Study of standard soap education effectiveness on correct progress note registering in medical records among surgical residents. J Med Educ Dev. 2018;11:81-93
  • 19. Patel A, Ali A, Lutfi F, Nwosu-Lheme A, Markham MJ. An Interactive Multimodality Curriculum Teaching Medicine Residents About Oncologic Documentation and Billing. MedEdPORTAL. 2018;14:10746.
  • 20. Sarzynski E, Foley K, Riekse R, Laird-Fick H, Keilman L, Barnikow T, et al. An OSCE to Assess Trainee Management of Complex Older Adults and to Teach Documentation, Coding, and Billing. MedEdPORTAL. 2014;10:9903.
  • 21. Shen E, Cristiano JA, Ellis LR. The Electronic Health Record Objective Structured Clinical Examination Station: Assessing Student Competency in Patient Notes and Patient Interaction. MedEdPORTAL. 2020;16:10998.
  • 22. Zavodnick J, Kouvatsos T. Electronic Health Record Skills Workshop for Medical Students. MedEdPORTAL. 2019;15:10849.
  • 23. Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors. Teach Learn Med. 2012;24:219-24.
  • 24. Hammoud MM, Dalymple JL, Christner JG, Stewart RA, Fisher J, Margo K, et al. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24:257-66.

Bir Tıp Fakültesinde Klinik Kayıt Tutma Eğitimindeki İhtiyacı Belirlemeye ve Klinik Kayıtlar Niteliği Üzerine Bir Çalışma

Yıl 2023, Cilt: 15 Sayı: 2, 257 - 265, 22.06.2023
https://doi.org/10.18521/ktd.1259969

Öz

Amaç: Klinik kayıt tutma ile ilgili olarak üniversitemizde lisans eğitimindeki ihtiyacı belirlemeyi ve ihtiyaç analizi sonucuna göre uygulanacak eğitim programının içeriğinde hangi konuların yer alması gerektiğine dair bir program önerisi sunmayı amaçladık.
Metod: Çalışmamız nitel araştırma türünde olup betimsel araştırma yöntemi kullanılmıştır. Klinik kayıt tutma eğitimi ihtiyacını belirlemek için 2022-2023 eğitim öğretim yılında Tıp Fakültesinde görevli 10 öğretim üyesi ile yarı-yapılandırılmış form aracılığıyla görüşmeler gerçekleştirilmiştir. Ayrıca Tıp Fakültesi öğrencilerinin ihtiyaçları belirlemek için 17 soruluk anket formu kullanılmıştır.
Bulgular: Çalışmaya 102 öğrenci katıldı. Katılımcıların 82’si (80.4%) klinik kayıt tutma ile ilgili eğitim almadığını belirtti. 7’li Likert tipi ölçekle değerlendirilen tuttuğunuz kayıtları ne kadar yeterli görüyorsunuz ve hasta notu yazarken kendinizi ne kadar rahat hissediyorsunuz sorularına verilen cevapların puanları ise sırasıyla 3.89±1.66 ve 3.55±1.74 olarak hesaplandı. Öğrencilerin 92 (90.2%)’si klinik kayıt tutmanın nasıl olması gerektiği ile ilgili ders almanın gerekli olduğunu düşünmekteydi. Yarı-yapılandırılmış formla yaptığımız görüşmelere 10 öğretim üyesi katıldı. Görüşmelerde klinik kayıtların niteliği ile ilgili olarak klinik kayıtların kapsamlı olması, kullanışlı olması, uygun dil kullanılması gibi temalar ön plana çıkmıştır. Klinik kayıt tutma açısından eksikliklerin sebepleri sorgulandığında eğitim sistemi sorunları ve yoğunlukla birlikte eğitim eksikliği ön plana çıkmıştır. Yapılacak eğitimler için birer yol gösterici olabilecek başlıklarımız kayıtların formatı, içeriği, yazımı ve kayıtlardan doğan hukuki sorumluluk olarak çalışmamızda öne çıkmıştır.
Sonuç: Fakültemizde klinik kayıtlar konusundaki eksiklik ve ihtiyaçları belirlediğimizi, ilerde buna uygun eğitim öğretim faaliyetlerinin gerçekleştirilmesinin klinik kayıtların niteliğini artıracağını düşünmekteyiz.

Kaynakça

  • 1. Rowlands S, Coverdale S, Callen J. Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education. Health Inf Mana. 2016;45:99-106.
  • 2. Kuhn T, Basch P, Barr M, Yackel T. Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162:301-3.
  • 3. Haghighi MH, Dehghani M, Teshnizi SH, Mahmoodi H. Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. Health Inf Manag. 2014;43:35-42.
  • 4. Seo JH, Kong HH, Im SJ, Roh H, Kim DK, Bae HO, Oh YR. A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean J Med Educ. 2016;28:237-41.
  • 5. Yılmaz BK, Topcu H, Acar YA. Assessment of legal obligations of physicians from emergency physician perspective. Med Bull Sisli Etfal Hosp. 2017;51: 142-8
  • 6. Jackson T. Data quality: not selling ourselves short. Health Inf Manag. 2014;43:4-6.
  • 7. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust. 2008;188:506-9.
  • 8. Alromaihi D, Godfrey A, Dimoski T, Gunnels P, Scher E, Baker-Genaw K. Internal medicine residents' time study: paperwork versus patient care. J Grad Med Educ. 2011;3:550-3.
  • 9. Oxentenko AS, West CP, Popkave C, Weinberger SE, Kolars JC. Time spent on clinical documentation: a survey of internal medicine residents and program directors. Arch Intern Med. 2010;170:377-80.
  • 10. Friedman E, Sainte M, Fallar R. Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Acad Med. 2010;85:1440-4.
  • 11. Mezuniyet Öncesi Ulusal Çekirdek Eğitim Programı; 2020 [cited 2023 Jan 23]. Available from: https://www.yok.gov.tr/Documents/Kurumsal/egitim_ogretim_dairesi/Ulusal-cekirdek-egitimi-programlari/mezuniyet-oncesi-tip-egitimi-cekirdek-egitimi-programi.pdf
  • 12. Köse A, Köse B, Öncü MR, Tuğrul F. Bir devlet hastanesi acil servisine başvuran hastaların profili ve başvurunun uygunluğu. Gaziantep Medical Journal. 2011;17:57-62.
  • 13. Dönmez SS, Durak VA, Torun G, Köksal Ö, Aydın Ş. Acil Serviste Gerçekleştirilen Konsültasyon Sürecinin İncelenmesi. Uludağ Tıp Derg. 2017;43:23-8.
  • 14. Borkan J. Immersion-crystallization. In: Crabtree BF, Miller WL, editors. Doing qualitative research (Research Methods for Primary Care) Newbury Park: Sage Publications; 1999. p. 179-84.
  • 15. Lai J, Tillman D. Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship. MedEdPORTAL. 2021;17:11194.
  • 16. Dawson B, Carter K, Brewer K, Lawson L. Chart smart: a need for documentation and billing education among emergency medicine residents? West J Emerg Med. 2010;11:116-9.
  • 17. Fakhry SM, Robinson L, Hendershot K, Reines HD. Surgical residents' knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg. 2007;194:263-7.
  • 18. Malekpour N, Noori A, SamadPour Amlashi T. Study of standard soap education effectiveness on correct progress note registering in medical records among surgical residents. J Med Educ Dev. 2018;11:81-93
  • 19. Patel A, Ali A, Lutfi F, Nwosu-Lheme A, Markham MJ. An Interactive Multimodality Curriculum Teaching Medicine Residents About Oncologic Documentation and Billing. MedEdPORTAL. 2018;14:10746.
  • 20. Sarzynski E, Foley K, Riekse R, Laird-Fick H, Keilman L, Barnikow T, et al. An OSCE to Assess Trainee Management of Complex Older Adults and to Teach Documentation, Coding, and Billing. MedEdPORTAL. 2014;10:9903.
  • 21. Shen E, Cristiano JA, Ellis LR. The Electronic Health Record Objective Structured Clinical Examination Station: Assessing Student Competency in Patient Notes and Patient Interaction. MedEdPORTAL. 2020;16:10998.
  • 22. Zavodnick J, Kouvatsos T. Electronic Health Record Skills Workshop for Medical Students. MedEdPORTAL. 2019;15:10849.
  • 23. Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors. Teach Learn Med. 2012;24:219-24.
  • 24. Hammoud MM, Dalymple JL, Christner JG, Stewart RA, Fisher J, Margo K, et al. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24:257-66.
Toplam 24 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Sağlık Kurumları Yönetimi
Bölüm Makaleler
Yazarlar

Emre Emekli 0000-0001-5989-1897

Özlem Coşkun 0000-0001-8716-1584

Işıl İrem Budakoğlu 0000-0003-1517-3169

Yavuz Selim Kıyak 0000-0002-5026-3234

Yayımlanma Tarihi 22 Haziran 2023
Kabul Tarihi 19 Haziran 2023
Yayımlandığı Sayı Yıl 2023 Cilt: 15 Sayı: 2

Kaynak Göster

APA Emekli, E., Coşkun, Ö., Budakoğlu, I. İ., Kıyak, Y. S. (2023). Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations. Konuralp Medical Journal, 15(2), 257-265. https://doi.org/10.18521/ktd.1259969
AMA Emekli E, Coşkun Ö, Budakoğlu Iİ, Kıyak YS. Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations. Konuralp Medical Journal. Haziran 2023;15(2):257-265. doi:10.18521/ktd.1259969
Chicago Emekli, Emre, Özlem Coşkun, Işıl İrem Budakoğlu, ve Yavuz Selim Kıyak. “Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations”. Konuralp Medical Journal 15, sy. 2 (Haziran 2023): 257-65. https://doi.org/10.18521/ktd.1259969.
EndNote Emekli E, Coşkun Ö, Budakoğlu Iİ, Kıyak YS (01 Haziran 2023) Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations. Konuralp Medical Journal 15 2 257–265.
IEEE E. Emekli, Ö. Coşkun, I. İ. Budakoğlu, ve Y. S. Kıyak, “Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations”, Konuralp Medical Journal, c. 15, sy. 2, ss. 257–265, 2023, doi: 10.18521/ktd.1259969.
ISNAD Emekli, Emre vd. “Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations”. Konuralp Medical Journal 15/2 (Haziran 2023), 257-265. https://doi.org/10.18521/ktd.1259969.
JAMA Emekli E, Coşkun Ö, Budakoğlu Iİ, Kıyak YS. Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations. Konuralp Medical Journal. 2023;15:257–265.
MLA Emekli, Emre vd. “Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations”. Konuralp Medical Journal, c. 15, sy. 2, 2023, ss. 257-65, doi:10.18521/ktd.1259969.
Vancouver Emekli E, Coşkun Ö, Budakoğlu Iİ, Kıyak YS. Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations. Konuralp Medical Journal. 2023;15(2):257-65.