Sujatha K.1 , Devivaraprasad M. 2 Chitra Nagaraj3 , Shakuntala Rao N.4 , Harsha P. J. 5
BACKGROUND Teaching of documentation to newly joined M.B.B.S students as a part of foundation course is important. We wanted to evaluate the improvement in knowledge regarding medical documentation as a part of early exposure to clinical aspects based on foundation course for new curriculum by Medical Council of India. METHODS This is a cross-sectional, retrospective study conducted from October to November 2019 at PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh. A total of 141 first year newly joined medical students were given pre-test on documentation followed by classroom teaching on medical documentation. Posttest was given at the end of the session. Data obtained was analysed in percentage. RESULTS Gain in knowledge was seen in various aspects of consent process (wrong responses < 10% at post-test). Knowledge regarding registration and admission process, medication order documentation in case records and consent before blood transfusion was good even before the teaching session (wrong responses at pre-test <10%). There was worsening in knowledge need of documentation of drug given during emergency even after teaching session (wrong responses increased from 36.17% to 41.84%). Knowledge regarding duration of maintenance of medical records, not to use unapproved abbreviations, documentation of patient details in each case sheet, documentation of initial assessment and oral orders within the time frame (24 hours), signature of consultant along with date and time daily, documentation of food/drug allergies though showed improvement, needs further reinforcement in these areas. CONCLUSIONS Medical documentation is important legally and provides an overall correct description of each patient’s details of care. The usual mistakes done in practice such as- 1. summaries given to relatives after death. 2. not using unapproved abbreviations. 3. documentation of initial assessment within 24 hours. 4. documentation of oral orders within 24 hours. 5. need of documenting the drugs given in emergency. 6. daily notes to be counter signed along with date and time by the consultant. 7. documentation of any food allergy, showed improvement at post-test, but not as expected. These above mentioned areas need to be addressed and reinforced in future teaching and clinical practice, so that mistakes committed can be minimized in future.
