| Are Students Less Likely to Report Pertinent Negatives in Post-encounter Notes? | |
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MedLine Citation:
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PMID: 22241337 Owner: NLM Status: In-Data-Review |
Abstract/OtherAbstract:
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BACKGROUND AND OBJECTIVES: In completing post-encounter notes (PENs), students are believed to under-report about 30% of the important information obtained in the medical history. The resulting incomplete clinical notes can contribute to adverse patient care and medicolegal outcomes. We hypothesized that pertinent negative items would be more likely to be under-reported than positive items. We compared reporting rates for pertinent positive and negative items on two cases in a clinical skills assessment (CSA) taken by all 55 third-year students. Based on standardized patient (SP) checklists, students obtained 87% of both positive and negative items. Scoring of PENs found significant differences in the reporting rates for positive (75%) and negative (52%) items. These results were consistent for each case. Students appear to be able to elicit pertinent negative information from patients but, although these items may be crucial in the medical history, they are significantly more likely than positive items to be omitted from the clinical note. |
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Authors:
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Anne Walling; Scott E Moser; Gretchen Dickson; Rosalee E Zackula |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Family medicine Volume: 44 ISSN: 1938-3800 ISO Abbreviation: Fam Med Publication Date: 2012 Jan |
Date Detail:
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Created Date: 2012-01-13 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 8306464 Medline TA: Fam Med Country: United States |
Other Details:
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Languages: eng Pagination: 22-5 Citation Subset: IM |
Affiliation:
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Department of Family and Community Medicine, University of Kansas School of Medicine-Wichita. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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