Patricoski C T, Shannon K, Doyle G A
Department of Family Medicine, West Virginia University, Morgantown, USA.
Fam Med. 1998 Jul-Aug;30(7):487-9.
Family medicine predoctoral programs frequently have medical students record patient diagnoses in logbooks. Little is known about the accuracy of such logbooks. No studies have compared patient records dictated by students with cases recorded in logbooks.
Over 2 years, all patient encounters dictated by 79 medical students during their 8-week family medicine rotations were recorded and compared with information in the students' logbooks.
Students dictated 2,520 patient encounters but only recorded 2,085 (82.7%) of them in their logbooks. Still, this rate of inclusion is higher than other studies where students did not dictate patient encounters. On the average, each student saw and dictated 32 patient encounters but omitted five to six from their logs. There were no significant differences between the 10 honors and 69 non-honors students in the proportion of patients omitted from logbooks.
Medical students underreport patient encounters in clerkship logbooks. Keeping a record of the patients dictated by medical students was helpful in determining the accuracy of students' logbooks.
家庭医学博士前项目经常让医学生在日志中记录患者诊断情况。对于此类日志的准确性了解甚少。尚无研究将学生口述的患者记录与日志中记录的病例进行比较。
在两年多的时间里，记录了79名医学生在为期8周的家庭医学轮转期间口述的所有患者诊疗情况，并与学生日志中的信息进行比较。
学生口述了2520次患者诊疗情况，但仅在日志中记录了其中的2085次（82.7%）。不过，这个纳入率高于其他学生未口述患者诊疗情况的研究。平均而言，每名学生诊疗并口述了32次患者诊疗情况，但在日志中遗漏了五到六次。在日志中遗漏患者的比例方面，10名优秀学生和69名非优秀学生之间没有显著差异。
医学生在临床实习日志中少报患者诊疗情况。记录医学生口述的患者情况有助于确定学生日志的准确性。
