title: Assessment of junior doctors' admission notes: do they follow what they learn?
abstract: OBJECTIVE
  To assess the completeness of history-taking and physical-examination notes of junior doctors at King Abdulaziz University Hospital per the approach they learned in medical school.
  
  
  METHODS
  In this retrospective study, we reviewed 860 admission notes written by 269 junior doctors (interns and residents) in an academic tertiary-care medical centre in Jeddah, Saudi Arabia, over a two-month period. Notes were evaluated for completeness using a checklist developed with reference to relevant medical textbooks. The checklist included 32 items related to history-taking and physical examination. Based on the review of the notes, checklist items were evaluated as complete, incomplete, not present, or not applicable according to set criteria. Data were analysed and summarised for information on the frequency and relative frequency of these types.
  
  
  RESULTS
  The history items varied in completeness. At the high end, asking about chief complaint and duration, associated symptoms, aggravating and relieving factors, and conducting systemic review were marked 'complete' in 74.2%, 81.7%, 80.4%, and 79.7% of notes, respectively. At the low end, asking about previous episodes, allergies, medications, and family history were complete in 5.3%, 1.9%, 4.8%, and 2.9% of notes, respectively. All physical examination items were poorly documented, especially breast examination, which was 'not present' in 95.8% of the notes.
  
  
  CONCLUSIONS
  Junior doctors' history and physical-examination notes are often incomplete and do not follow the approach taught in medical school. The reasons for this must be studied via focus-group discussions with junior doctors.
authors.affiliation: Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Rashid A
authors.initials: RA
authors.lastname: Barnawi
authors.affiliation: Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Abdulaziz M
authors.initials: AM
authors.lastname: Ghurab
authors.affiliation: Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Hassan K
authors.initials: HK
authors.lastname: Balubaid
authors.affiliation: Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Sultan S
authors.initials: SS
authors.lastname: Alfaer
authors.affiliation: Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Kamal A
authors.initials: KA
authors.lastname: Hanbazazah
authors.affiliation: Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Mohammed F
authors.initials: MF
authors.lastname: Bukhari
authors.affiliation: Quality and Academic Accreditation Unit, Medical Education Department, Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Omayma A
authors.initials: OA
authors.lastname: Hamed
authors.affiliation: Department of Surgery, Faculty of Medicine, King Abdulaziz University, Saudi Arabia.
authors.forename: Talal M
authors.initials: TM
authors.lastname: Bakhsh
mesh_terms: D000046:Academic Medical Centers; D057189:Checklist; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D008487:Medical History Taking / Q000592:standards*; D008505:Medical Staff, Hospital / Q000592:standards*; D010343:Patient Admission / Q000592:standards; D010808:Physical Examination / Q000592:standards; D010820:Physicians / Q000592:standards*; D012189:Retrospective Studies; D012529:Saudi Arabia
keywords: admission notes assessment; admission notes completeness; history-taking; junior doctors; physical examination; saudi arabia