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Research Article
Jun-Neng Roan
National Cheng Kung University Hospital
Corresponding Author
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This work is licensed under a CC BY 4.0 License. Read Full License
Background Electronic medical records (EMRs) are becoming a predominant feature of health care and an important tool in residents’ medical education. Few studies have examined and compared the EMR performance of residents from different departments. This study explores the quality of EMRs in residency and offers pedagogical implications.
Method Authors developed an EMR checklist which examined fundamental EMR requirement through six dimensions and 20 items. A total of 149 records created by residents from 32 departments/stations were randomly chosen. Seven senior physicians rated the EMRs using the checklist. Medical records were grouped as General Medicine, Surgery, Pediatric, Obstetrics and Gynecology and Other Departments. Overall and grouped performances were analyzed by ANOVA.
Results Overall performance was rated as fair to good. Regarding the six dimensions, the discharge note (0.81) gained the highest scores, followed by the admission note (0.79), problem list (0.73), overall performance (0.73), progress note (0.71), and weekly summary (0.66).
Among the five groups, Other Departments (80.20) gained the highest total score, followed by Obstetrics and Gynecology (78.02), Pediatrics (77.47), General Medicine (75.58), and Surgery (73.92).
Conclusions The quality of EMRs, core competencies, and clinical reasoning skills are deeply interconnected in resident education. This study suggested that the use of duplication in EMR, and the communication abilities of residents are associated with the variable quality of medical records in different departments. Further study is required to apply the insights obtained in this study to improve the quality of EMRs, and thereby the effectiveness of resident training.
Keywords
Electronic medical record, Quality improvement, Resident education, Clinical reasoning
No competing interests reported.
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Peer Review Timeline
CURRENT STATUS: Under Review
Version 1
Posted 26 Feb, 2021
No community comments so far
Editorial decision: Major revision
On 16 Jul, 2021
Reviews received
Received 29 Apr, 2021
Reviewers agreed
On 31 Mar, 2021
Reviewers invited
Invitations sent on 02 Mar, 2021
Editor assigned
On 28 Feb, 2021
Editor invited
On 25 Feb, 2021
Submission checks complete
On 25 Feb, 2021
First submitted
On 12 Feb, 2021
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Educational Philosophy and Theory
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A new preprint design is coming!
We have improved readability, clarity, accessibility, and opportunities for engagement.
This preprint is under consideration at BMC Medical Education. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research Article
Jun-Neng Roan
National Cheng Kung University Hospital
Corresponding Author
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 1
Posted 26 Feb, 2021
No community comments so far
Editorial decision: Major revision
On 16 Jul, 2021
Reviews received
Received 29 Apr, 2021
Reviewers agreed
On 31 Mar, 2021
Reviewers invited
Invitations sent on 02 Mar, 2021
Editor assigned
On 28 Feb, 2021
Editor invited
On 25 Feb, 2021
Submission checks complete
On 25 Feb, 2021
First submitted
On 12 Feb, 2021
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Educational Philosophy and Theory
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background Electronic medical records (EMRs) are becoming a predominant feature of health care and an important tool in residents’ medical education. Few studies have examined and compared the EMR performance of residents from different departments. This study explores the quality of EMRs in residency and offers pedagogical implications.
Method Authors developed an EMR checklist which examined fundamental EMR requirement through six dimensions and 20 items. A total of 149 records created by residents from 32 departments/stations were randomly chosen. Seven senior physicians rated the EMRs using the checklist. Medical records were grouped as General Medicine, Surgery, Pediatric, Obstetrics and Gynecology and Other Departments. Overall and grouped performances were analyzed by ANOVA.
Results Overall performance was rated as fair to good. Regarding the six dimensions, the discharge note (0.81) gained the highest scores, followed by the admission note (0.79), problem list (0.73), overall performance (0.73), progress note (0.71), and weekly summary (0.66).
Among the five groups, Other Departments (80.20) gained the highest total score, followed by Obstetrics and Gynecology (78.02), Pediatrics (77.47), General Medicine (75.58), and Surgery (73.92).
Conclusions The quality of EMRs, core competencies, and clinical reasoning skills are deeply interconnected in resident education. This study suggested that the use of duplication in EMR, and the communication abilities of residents are associated with the variable quality of medical records in different departments. Further study is required to apply the insights obtained in this study to improve the quality of EMRs, and thereby the effectiveness of resident training.
No competing interests reported.
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