Evaluation of Medical Records Written by Students During Pediatric Bedside Learning.

DOI 3 Citations 12 References
  • EGUCHI Mitsuoki
    The Second Department of Pediatrics, Dokkyo University, School of Medicine
  • FURUKAWA Toshiharu
    The Second Department of Pediatrics, Dokkyo University, School of Medicine
  • UMINO Takeshi
    The Second Department of Pediatrics, Dokkyo University, School of Medicine
  • SUGITA Kenichi
    The Second Department of Pediatrics, Dokkyo University, School of Medicine

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  • クリニカル・クラークシップを目指した小児科ＢＳＬでの学生の診療録記載とその評価

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Abstract

Participation of students in the management of patients was evaluated by analyzing medical records written by the students. Sixty-four percent of the students wrote in the medical chart everyday, however the amount of data was on average only 5.6 lines per day. Descriptions of subjective data were scant. Physical complaints were described for 65% of patients, but were insufficient in detail. Psychic and social complaints were rarely described. Objective data on the physical examination comprised the main body of chart notes recorded by the students, although only 37% of these were judged to be sufficient. Laboratory and radiological data were described less thoroughly than data from the physical examination, and were completely absent from 64% of charts. Assessments were incomplete, and patient problems were not clearly elucidated for most patients. These undergraduate students failed in their assessment of patient problems during their one week of bedside learning.

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