Analysis of Clinical Record-Keeping Education in Turkish Medical Faculties: Evaluation of Curriculum Programs
Öz
Objective: Aimed to review the clinical record-keeping (CRK) courses offered in Turkish medical faculties and to determine their distribution according to topics. Additionally, considering the importance of early clinical experience in developing record-keeping skills, it aimed to assess the emphasis on practical and theoretical courses in the preclinical period.
Methods: The pre-graduation education programs of medical faculties in Turkey with students in the 2023-2024 academic year were accessed through faculty websites. 122 out of 148 medical faculties were included in the study. All courses related to CRK were recorded in terms of their hours, the class in which they were offered, and whether they were practical or theoretical. Recorded course names were grouped under headings.
Results: Education programs of 86 (70.5%) of faculties were obtained. Of the total 1351 course hours related to CRK, 31.8% (429 hours) were theoretical, 9.6% (129 hours) were practical in the preclinical period; 58.7% (793 hours) were taught theoretically in the clinical period. The majority of theoretical courses (70.8%) were related to taking anamnesis, followed by legal document preparation (8.9%) and prescription writing (7.6%). Practical courses: 7.4% (100 hours) were on taking anamnesis. Courses on writing epicrises and electronic health records were quite limited.
Conclusion: Majority of CRK courses were offered in the clinical period and were theoretical. The limited number of practical courses may restrict students' opportunities to develop this skill. Increasing practical applications, especially in the preclinical period, can help students acquire CRK skills early and become more competent physicians after graduation. Therefore, it is recommended to increase the number and quality of CRK courses.
Anahtar Kelimeler
Clinical record keeping Medical education Training program Preclinical education Medical schools
Kaynakça
- 1. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe (Sheff). 2016;12(4):369-73.
- 2. Adane K, Muluye D, Abebe M. Processing medical data: a systematic review. Arch Public Health. 2013;71(1):27.
- 3. Vos JFJ, Boonstra A, Kooistra A, Seelen M, van Offenbeek M. The influence of electronic health record use on collaboration among medical specialties. BMC Health Serv Res. 2020;20(1):676.
- 4. Guarducci G, Sanguineti I, Cuccaro C, Randisi R, Messina G, Nante N. Improving the quality of medical records. European Journal of Public Health. 2022;32 (Supplement_3).
- 5. Massey PR, Anderson JH. Resuscitating inpatient clinical clerkships: a medical student perspective. JAMA Intern Med. 2014;174(9):1440-1.
- 6. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust. 2008;188(9):506-9.
- 7. Alromaihi D, Godfrey A, Dimoski T, Gunnels P, Scher E, Baker-Genaw K. Internal medicine residents' time study: paperwork versus patient care. J Grad Med Educ. 2011;3(4):550-3.
- 8. Emekli E, Coşkun O, Budakoğlu II, Kıyak YS. Clinical record keeping education needs in a medical school and the quality of clinical documentations. Konuralp Medical Journal. 2023;15(2):257-65.
- 9. Charnock V. Electronic healthcare records and data quality. Health Info Libr J. 2019;36(1):91-5.
- 10. Council of Higher Education. Undergraduate Programs Atlas [Internet]. Turkiye [cited 2024 Aug 15] Available from: https://yokatlas.yok.gov.tr/lisans-anasayfa.php
- 11. Emekli E, Coşkun O, Budakoğlu II. Medical record-keeping educational interventions for medical students and residents: a systematic review. Health Inf Manag. 2024:18333583241269031.
- 12. Weber DE, Held JD, Jandarov RA, Kelleher M, Kinnear B, Sall DR, et al. Improving trainee clinical documentation through a novel curriculum in internal medicine. J Hosp Med. 2022;17(1):28-35.
- 13. Severn Audit and Research Collaborative in Orthopaedics (SARCO). Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient Saf Surg. 2016;10:5.
- 14. Surapaneni KM. Influence of Competitive Entrance Exams on Medical Students' Preferences to Non-traditional Learning Resources. Med Sci Educ. 2023;33(6):1437.
- 15. Emekli E, Kıyak YS. Comprehensiveness and instructional quality of youtube videos on clinical record-keeping training in medical education. Konuralp Medical Journal. 2024;16(2):154-60.
- 16. Glisson JK, Morton ME, Bond AH, Griswold M. Does an education intervention improve physician signature legibility? Pilot study of a prospective chart review. Perspect Health Inf Manag. 2011;8(Summer):1e.
- 17. Ming D, Zietlow K, Song Y, Lee HJ, Clay A. Discharge summary training curriculum: a novel approach to training medical students how to write effective discharge summaries. Clin Teach. 2019;16(5):507-12.
- 18. Nadeem N, Zafar AM, Haider S, Zuberi RW, Ahmad MN, Ojili V. Chart-stimulated Recall as a Learning Tool for Improving Radiology Residents' Reports. Acad Radiol. 2017;24(8):1023-6.
- 19. Wurster F, Beckmann M, Cecon-Stabel N, Dittmer K, Hansen TJ, Jaschke J, et al. The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis. JMIR Med Inform. 2024;12:e47761.
- 20. Comeau R, Craig C. Does teaching of documentation of shoulder dystocia delivery through simulation result in improved documentation in real life? J Obstet Gynaecol Can. 2014;36(3):258-65.
- 21. Sayyah-Melli M, Nikravan Mofrad M, Amini A, Piri Z, Ghojazadeh M, Rahmani V. The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences. J Caring Sci. 2017;6(3):281-92.
Türkiye'deki Tıp Fakültelerinde Klinik Kayıt Tutma Eğitiminin Analizi: Ders Programlarının Değerlendirilmesi
Öz
Amaç: Türkiye'deki tıp fakültelerinde verilen klinik kayıt tutma (KK) derslerinin taranması ve derslerin konulara göre dağılımlarının belirlenmesi amaçlanmıştır. Ayrıca, kayıt tutma becerilerinin geliştirilmesinde erken klinik deneyimin önemini göz önünde bulundurarak, klinik öncesi dönemdeki pratik ve teorik derslerin ağırlığının belirlenmesi hedeflenmiştir.
Yöntem: 2023-2024 eğitim-öğretim yılında Türkiye'deki tıp fakültelerinin mezuniyet öncesi eğitim programlarına fakültelerin internet siteleri üzerinden ulaşıldı. 148 tıp fakültesinden 122'si çalışmaya dahil edildi. KK ile ilgili tüm derslerin saati, verildiği sınıf ve pratik veya teorik olup olmadığı kaydedildi. Kaydedilen ders isimleri daha sonra ortak başlıklar altında toplandı.
Bulgular: Çalışmaya dahil edilen 122 fakülteden 86'sının (%70,5) eğitim programlarına ulaşıldı. Toplam 1351 ders saatinin %31,8'i (429 saat) klinik öncesi dönemde teorik, %9,6'sı (129 saat) pratik; %58,7'si (793 saat) ise klinik dönemde teorik olarak veriliyordu. Teorik derslerin büyük çoğunluğu (%70,8) anamnez alma ile ilgiliydi, bunu adli belge hazırlama (%8,9) ve reçete yazma (%7,6) takip etti. Pratik derslerin ise %7,4'ü (100 saat) anamnez alma üzerineydi. Epikriz yazma ve elektronik sağlık kayıtları ile ilgili dersler oldukça sınırlıydı.
Sonuç: KK tutma derslerinin büyük çoğunluğunun klinik dönemde ve teorik olarak verildiği belirlenmiştir. Pratik derslerin sınırlı olması, öğrencilerin bu beceriyi geliştirme fırsatını kısıtlayabilir. Özellikle klinik öncesi dönemde pratik uygulamaların artırılması, öğrencilerin KK tutma becerilerini erken dönemde kazanmalarına ve mezuniyet sonrasında daha yetkin hekim olmalarına katkı sağlayabilir. Bu nedenle, tıp fakültelerinde KK tutma derslerinin sayısının ve niteliğinin artırılması önerilmektedir.
Anahtar Kelimeler
Klinik kayıt tutma Tıp eğitimi Eğitim programı Klinik öncesi eğitim Tıp fakülteleri
Kaynakça
- 1. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe (Sheff). 2016;12(4):369-73.
- 2. Adane K, Muluye D, Abebe M. Processing medical data: a systematic review. Arch Public Health. 2013;71(1):27.
- 3. Vos JFJ, Boonstra A, Kooistra A, Seelen M, van Offenbeek M. The influence of electronic health record use on collaboration among medical specialties. BMC Health Serv Res. 2020;20(1):676.
- 4. Guarducci G, Sanguineti I, Cuccaro C, Randisi R, Messina G, Nante N. Improving the quality of medical records. European Journal of Public Health. 2022;32 (Supplement_3).
- 5. Massey PR, Anderson JH. Resuscitating inpatient clinical clerkships: a medical student perspective. JAMA Intern Med. 2014;174(9):1440-1.
- 6. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust. 2008;188(9):506-9.
- 7. Alromaihi D, Godfrey A, Dimoski T, Gunnels P, Scher E, Baker-Genaw K. Internal medicine residents' time study: paperwork versus patient care. J Grad Med Educ. 2011;3(4):550-3.
- 8. Emekli E, Coşkun O, Budakoğlu II, Kıyak YS. Clinical record keeping education needs in a medical school and the quality of clinical documentations. Konuralp Medical Journal. 2023;15(2):257-65.
- 9. Charnock V. Electronic healthcare records and data quality. Health Info Libr J. 2019;36(1):91-5.
- 10. Council of Higher Education. Undergraduate Programs Atlas [Internet]. Turkiye [cited 2024 Aug 15] Available from: https://yokatlas.yok.gov.tr/lisans-anasayfa.php
- 11. Emekli E, Coşkun O, Budakoğlu II. Medical record-keeping educational interventions for medical students and residents: a systematic review. Health Inf Manag. 2024:18333583241269031.
- 12. Weber DE, Held JD, Jandarov RA, Kelleher M, Kinnear B, Sall DR, et al. Improving trainee clinical documentation through a novel curriculum in internal medicine. J Hosp Med. 2022;17(1):28-35.
- 13. Severn Audit and Research Collaborative in Orthopaedics (SARCO). Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient Saf Surg. 2016;10:5.
- 14. Surapaneni KM. Influence of Competitive Entrance Exams on Medical Students' Preferences to Non-traditional Learning Resources. Med Sci Educ. 2023;33(6):1437.
- 15. Emekli E, Kıyak YS. Comprehensiveness and instructional quality of youtube videos on clinical record-keeping training in medical education. Konuralp Medical Journal. 2024;16(2):154-60.
- 16. Glisson JK, Morton ME, Bond AH, Griswold M. Does an education intervention improve physician signature legibility? Pilot study of a prospective chart review. Perspect Health Inf Manag. 2011;8(Summer):1e.
- 17. Ming D, Zietlow K, Song Y, Lee HJ, Clay A. Discharge summary training curriculum: a novel approach to training medical students how to write effective discharge summaries. Clin Teach. 2019;16(5):507-12.
- 18. Nadeem N, Zafar AM, Haider S, Zuberi RW, Ahmad MN, Ojili V. Chart-stimulated Recall as a Learning Tool for Improving Radiology Residents' Reports. Acad Radiol. 2017;24(8):1023-6.
- 19. Wurster F, Beckmann M, Cecon-Stabel N, Dittmer K, Hansen TJ, Jaschke J, et al. The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis. JMIR Med Inform. 2024;12:e47761.
- 20. Comeau R, Craig C. Does teaching of documentation of shoulder dystocia delivery through simulation result in improved documentation in real life? J Obstet Gynaecol Can. 2014;36(3):258-65.
- 21. Sayyah-Melli M, Nikravan Mofrad M, Amini A, Piri Z, Ghojazadeh M, Rahmani V. The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences. J Caring Sci. 2017;6(3):281-92.
Ayrıntılar
| Birincil Dil | İngilizce |
|---|---|
| Konular | Sağlık Hizmetleri ve Sistemleri (Diğer) |
| Bölüm | Makaleler |
| Yazarlar | |
| Yayımlanma Tarihi | 17 Haziran 2025 |
| Gönderilme Tarihi | 7 Ekim 2024 |
| Kabul Tarihi | 26 Mayıs 2025 |
| Yayımlandığı Sayı | Yıl 2025 Cilt: 17 Sayı: 2 |
Kaynak Göster
