title: Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital.
abstract: OBJECTIVE
  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%.
  
  
  CONCLUSIONS
  The study demonstrated that documentation of clinical notes by interns can be enhanced by formal tuition.
authors.affiliation: Emergency Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Isoardi
authors.forename: Lyndall
authors.initials: L
authors.lastname: Spencer
authors.forename: Michael
authors.initials: M
authors.lastname: Sinnott
authors.forename: Robert
authors.initials: R
authors.lastname: Eley
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D002983:Clinical Competence / Q000592:standards; D004282:Documentation / Q000592:standards*; D004503:Education, Medical, Graduate / Q000379:methods*; D004635:Emergency Medicine / Q000193:education*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008499:Medical Records / Q000592:standards*; D011793:Queensland; D012189:Retrospective Studies; D013663:Teaching / Q000379:methods*
keywords: interns; medical record documentation; teaching