Do students do what they write and write what they do? The match between the patient encounter and patient note.
BACKGROUND
Patient notes are used for a variety of purposes in health care. Medical students are taught the structure of patient notes early in training. Review of patient notes are then used to assess synthesis and integration of patient information. It is critical that the information in the note accurately and completely represents the student-patient encounter.


METHODS
The authors reviewed videotapes of students in three standardized-patient based scenarios and compared what occurred during the physical examination with the subsequent documentation in the patient note.


RESULTS
In all, 207 encounter-note pairs were reviewed. Only 8 (4%) of the notes completely and accurately represented what occurred during the encounter. Problems with underdocumentation, overdocumentation, and inaccurate documentation of physical findings were seen for all three patient scenarios.


CONCLUSIONS
These findings highlight the need to teach and assess both data gathering skills and written documentation of findings in medical training.
Szauter
Karen M
KM
University of Texas Medical Branch, 301 University Blvd, Galveston, Texas 77555-0420, USA. kszauter@utmb.edu
Ainsworth
Michael A
MA
Holden
Mark D
MD
Mercado
Anita C
AC
D004282:Documentation; D006801:Humans; D008499:Medical Records; D010808:Physical Examination; D013337:Students, Medical; D014743:Videotape Recording