Family practice clerkship encounters documented with structured phrases on paper and hand-held computer logs
Patient encounter logs allow faculty to monitor students' clinical experiences, especially in decentralized clerkships. However, there are generally tradeoffs involving the expressiveness of patient encounter forms, the effort required to complete the forms, and the utility of the forms for inf...
| Veröffentlicht in: | Proceedings. AMIA Symposium. - 1998. - (2000) vom: 01., Seite 547-50 |
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| Format: | Aufsatz |
| Sprache: | English |
| Veröffentlicht: |
2000
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| Zugriff auf das übergeordnete Werk: | Proceedings. AMIA Symposium |
| Schlagworte: | Journal Article |
| Zusammenfassung: | Patient encounter logs allow faculty to monitor students' clinical experiences, especially in decentralized clerkships. However, there are generally tradeoffs involving the expressiveness of patient encounter forms, the effort required to complete the forms, and the utility of the forms for informing the clerkship director. The family practice clerkship at Washington University changed the school's standard free text, paper log to a controlled vocabulary paper log, borrowing 93 generic ICD-9 codes and the SNOMED concept of 'process at location' phrases for localized problems. Subsequently, this architecture was used in a Palm computer program. Students using the structured paper logs documented slightly more patient encounters than students using free text logs in the previous year, with similar numbers of problems per patient (1.3 to 1.4) and prevalence of common illnesses, but used the phrase structure and code vocabulary inconsistently. Students using computer logs documented many more patient encounters, but only documented 1.09 problems per patient. Students' documentation of psychosocial diagnoses declined significantly with the computer log. Although the computer program was flexible, the effort required to enter multiple problems exceeded the effort of finding similar codes on a short paper form. This problem confounds efforts to monitor exposure to complex patients and hidden medical problems. Another design for the hand-held computer log is being tested |
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| Beschreibung: | Date Completed 08.03.2001 Date Revised 13.11.2018 published: Print Citation Status MEDLINE |
| ISSN: | 1531-605X |