Assessing the quality of electronic medical records as a platform for resident education.

ABSTRACT:

Background

Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants' medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications.

Methods

The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated t

SUBMITTER: Hung H 

PROVIDER: S-EPMC8590775 | biostudies-literature | 2021 Nov

REPOSITORIES: biostudies-literature