Evaluation of the congruence between students' postencounter notes and standardized patients' checklists in a clinical skills examination.
OBJECTIVE
Questions remain about the congruence between students' written notes and checklists as summaries of encounters.


METHODS
Students examined standardized patients and summarized findings in postencounter notes. The patients completed checklists. A physician read the students' notes and completed parallel checklists to document the history and physical items performed. Rates of under- and overdocumentation were calculated.


RESULTS
Students documented findings for 71% of items performed - an underdocumentation rate of 29%. Approximately 94% of their documented findings were consistent with what they had done. Their rate of overdocumentation was 6%, in which they documented findings inconsistent with the checklists. About half the students had no instances of overdocumentation.


CONCLUSIONS
Students' rate of underdocumentation was comparable to experienced clinicians. Although their overdocumentation rate was low overall, it was high for a few students. Evaluation of the congruence between checklists and postencounter notes provides useful information and informs checklist development.
Worzala
Katherine
K
Clinical Skills Center, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA. Katherine.Worzala@jefferson.edu
Rattner
Susan L
SL
Boulet
John R
JR
Majdan
Joseph F
JF
Berg
Dale D
DD
Robeson
Mary
M
Veloski
J Jon
JJ
D000328:Adult; D002982:Clinical Clerkship / Q000592:standards*; D002983:Clinical Competence / Q000592:standards*; D003479:Curriculum; D004504:Education, Medical, Undergraduate / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D010353:Patient Education as Topic / Q000592:standards*; D010414:Pennsylvania; D010806:Physical Education and Training / Q000379:methods*; D015203:Reproducibility of Results; D013337:Students, Medical