School of Dentistry, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Malaysia;.
J Dent Educ. 2014 Feb;78(2):206-12.
This study investigated the impact of clinical audit training on record-keeping behavior of dental students and students' perceptions of the clinical audit training. The training was delivered to Year 4 and Year 5 undergraduates at the School of Dentistry, International Medical University, Kuala Lumpur, Malaysia. It included a practical audit exercise on patient records. The results were presented by the undergraduates, and guidelines were framed from the recommendations proposed. Following this, an audit of Year 4 and Year 5 students' patient records before and after the audit training was carried out. A total of 100 records were audited against a predetermined set of criteria by two examiners. An email survey of the students was also conducted to explore their views of the audit training. Results showed statistically significant improvements in record-keeping following audit training. Responses to the email survey were analyzed qualitatively. Respondents reported that the audit training helped them to identify deficiencies in their record-keeping practice, increased their knowledge in record-keeping, and improved their record-keeping skills. Improvements in clinical audit teaching were also proposed.
本研究旨在探讨临床审计培训对牙科学生的病历记录行为和学生对临床审计培训的看法的影响。该培训在马来西亚吉隆坡国际医药大学牙科学院的四年级和五年级本科生中进行，包括对病历进行实际审计练习。学生们展示了他们的成果，并根据提出的建议制定了指导方针。在此之后，对临床审计培训前后的四年级和五年级学生的病历进行了审核。两名考官根据预定的标准对总共 100 份病历进行了审核。还对学生进行了电子邮件调查，以探讨他们对审计培训的看法。结果显示，审计培训后病历记录有了显著改善。对电子邮件调查的回复进行了定性分析。受访者报告说，审计培训帮助他们发现了病历记录实践中的缺陷，增加了他们在病历记录方面的知识，并提高了他们的病历记录技能。还提出了改进临床审计教学的建议。
