Sumner Walton, Campbell John, Irving Sarah C
Washington University, School of Medicine, St Louis, MO 63119, USA.
Fam Med. 2006 Nov-Dec;38(10):736-41.
Medical students increasingly log patient encounters on handheld computers. Detailed patient records captured at the bedside would allow these log programs to complement medical education with automated reminders. We evaluated progress toward this goal.
A series of electronic student encounter logs (ESEL) were designed to quickly record common diagnoses in a family medicine clerkship. Common diagnoses were organized in a shallow, broad-tree structure that locates many concepts with one to four taps. Third-year clerks' ESEL records of patient problems were evaluated longitudinally and across two similar clerkships. Grading criteria were introduced to encourage attention to target problems, especially infrequently reported psychosocial issues. A pilot reminder system in ESEL-4, the latest version of the computer application program, included 17 high-specificity reminders. Students' viewing of reminders was monitored.
Students recorded complex patients in ESEL-4 and entered 80% of patients during office hours. ESEL grading generated anxiety but was associated with significantly increased and plausible documentation of tobacco abuse, depression, and alcohol abuse. Students viewed titles of about 25% of generated reminders but reviewed less than 1% of reminders in detail.
Students using ESEL-4 document plausibly complex patients, usually during office hours. Grading probably improves completeness and accuracy. Diagnosis-driven educational reminder systems are possible but do not yet capture students' attention.
医学生越来越多地使用手持计算机记录患者诊疗情况。在床边获取的详细患者记录可使这些日志程序通过自动提醒对医学教育起到补充作用。我们评估了在实现这一目标方面取得的进展。
设计了一系列电子学生诊疗日志（ESEL），用于在家庭医学实习中快速记录常见诊断。常见诊断按照浅而广的树形结构进行组织，通过一到四次点击就能找到许多概念。对三年级实习生在两个相似实习阶段的患者问题ESEL记录进行纵向评估。引入评分标准以鼓励关注目标问题，特别是那些报告较少的社会心理问题。ESEL - 4（计算机应用程序的最新版本）中的一个试点提醒系统包含17条高特异性提醒。对学生查看提醒的情况进行了监测。
学生在ESEL - 4中记录了复杂患者情况，且80%的患者记录是在办公时间录入的。ESEL评分引发了焦虑，但与烟草滥用、抑郁和酒精滥用的记录显著增加且合理相关。学生查看了约25%生成的提醒标题，但详细查看的提醒不到1%。
使用ESEL - 4的学生通常在办公时间对复杂患者情况进行了合理记录。评分可能提高了记录的完整性和准确性。以诊断为驱动的教育提醒系统是可行的，但尚未引起学生的关注。
