Assessment of The Relevance of Admission Clerking Criteria Taught to Medical Students at King Abdulaziz University to Real Hospital Practice
An essential part of medical record is history taking and physical examination. Therefore, medical students at King Abdulaziz University are taught to take detailed history and perform thorough physical examination to patients at admission, and interns and residents are expected to adhere to that.
Here, we aim to assess the relevance of what students are being taught to what intern/residents actually do. To achieve that, we reviewed 860 admission notes of patients who were admitted for the first time during a two-month period andevaluated them using a checklist structured using the referenced textbooks for students. Elements in the checklist could be evaluated as informative, less informative, non-informative, not present or N/A, The average in formativeness index was calculated to investigate the overall extent of in formativeness.
The overall average in formativeness index was 50%. In the history taking, notes of “associated symptoms” were the most informative (82.4%) while previous episodes, family history, medications and allergies were informative in 5.6%, 2.9%, 4.8% and 1.9% of the notes, respectively. The physical examination part shows an overall extreme lack of in formativeness. In conclusion; the standards of history taking and physical examination that are taught to medical student are not completely applied in real hospital practice.
Index Terms— Admission Notes, Completeness, History Taking, Hospital Record, Interns/Residents Notes, Medical Record, Medical Students, Physical Examination.