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|Mohammed F. Bukhari, Rashid A. Barnawi, Abdulaziz M. Ghurab, Sultan S. Alfaer, Hassan K. Balubaid, Kamal A. Hanbazazah, Omayma A. Hamed and Talal M. Baksh|
|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.|
Mohammed started his undergraduate medical school program for which he was focusing on balancing between satisfying the course requirements and gaining hospital training. In addition, he participated in many researches with different specialties such as pediatric, medical education, nutrition. Mohammed is a medical intern who is working towards becoming a pediatrician, and he is going to graduate from King Abdulaziz University in 2017.
Email: [email protected]
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