Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital.

OBJECTIVES

This study's objective was to determine whether tuition in medical documentation enhanced the ability of emergency medicine interns to produce effective medical records.

METHODS

The study adopted a case control design, using a retrospective document audit methodology, following an education intervention during the 'More Learning for Interns in Emergency' (MoLIE) programme. It was conducted in a tertiary hospital that supports five 10 week rotations of 12 interns each year (n = 60). Controls were drawn from records written in March 2012 and cases from March 2013. A total of 250 medical records written by interns were audited, 125 from each year.

RESULTS

Three categories of documentation were investigated: patient characteristics, clinical impressions and management plan using a purpose-designed score sheet. Three individual items (differential diagnosis [DDX], Support and Impressions [Impress]) showed significant improvement. The proportion of excellent scores for DDX increased by 50% from 40.8% to 61.6%. A χ(2) test for independence (with Yates continuity correction) indicated a significant association between the intervention and subsequent score (X(2) [1, n = 250] = 10.006, P < 0.001, phi -0.208). For Impress, a 48% increase in excellent scores was seen (39.2% to 58.4%). A χ(2) test for independence indicated a significant association between the intervention and subsequent score (X(2) [2, n = 250] = 11.249, P = 0.004, Cramer's V 0.212). The variable Support also improved (X(2) [2, n = 250] = 8.297, P = 0.012, Cramer's V 0.189) with the number of excellent scores increasing from 37.6% to 48.0%.

CONCLUSION

The study demonstrated that documentation of clinical notes by interns can be enhanced by formal tuition.