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|Sultan S. Alfaer, Hassan K. Balubaid, Kamal A. Hanbazazah, Mohammed F. Bukhari, Omayma A. Hamed and Talal M. Baksh, Rashid A. Barnawi and Abdulaziz M. Ghurab|
|King Abdulaziz University, Saudi Arabia|
|Posters & Accepted Abstracts: J Gen Practice|
|Completeness of medical record is essential as deficiencies could pose risk to patients’ health. Interns/residents who do the admission clerking are therefore expected to take a detailed history and perform a thorough physical examination to all patients at admission. We are questioning the completeness of their notes according to what they had been taught as students. A retrospective study of 860 patients who were admitted during two months from 1st of December 2014 to 31st of January 2015. Admission notes were reviewed through the electronic medical record health information system and were evaluated using a checklist structured using the referenced textbooks for medical students. The data were summarized into frequency and relative frequency. Average informativeness index was calculated using Guilbert’s equation.The overall average informativeness index was 50%, which is unsatisfactory. In the history taking part of the survey, In the history taking part of the checklist, notes of “associated symptoms” were the most informative (82.4%) while previous episodes, family history, medication 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 informativeness especially breast examination that wasn’t documented informatively in any of the notes. This retrospective study delineated that the standards are not completely followed by interns/residents. Future research should be conducted regarding the reasons as an attempt to solve this issue.|
Sultan Saleh has been graduated from King Abdulaziz University as Medical Doctor May 2016. A Founding member of “Student Research and Innovation Unit” in association with Deanship of Graduate Studies and Research in Faculty of Medicine, King Abdulaziz University. 1st place as best student prepared presentation in Radiology rotation 2014. I have the passion for doing research. I have also been appointed leader of several projects.
Email: [email protected]
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