A pilot study to develop a tool for the assessment of students' clinical record keeping

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Moore, K, Vaughan, B & Cox, A 2017, 'A pilot study to develop a tool for the assessment of students' clinical record keeping', International Journal of Osteopathic Medicine, vol. 24, pp. 37-41.

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Background: The ability to develop and maintain contemporaneous and accurate clinical records is a medicolegal requirement. It follows therefore that preregistration health students' skills to write such ought to be assessed. Objective: The aim of the present study is to develop an audit tool to evaluate student clinical record keeping in university on-campus clinics. Methods: The project reported on here included a literature review to identify current practice in measuring accuracy in record keeping and to identify a suitable audit tool for educational purposes. We then adapted the tool to more closely align with Australian Health Practitioner Regulatory Agency requirements. We trialled the usability of the subsequent Tool in one university health clinic – in two disciplines. In each discipline, students' clinical records from ten initial consultations and ten subsequent consultations were evaluated using the Piloted Audit Tool (PAT). Results: The PAT was difficult to use due to the grading criteria. Notwithstanding, we identified important gaps in new patient consultation notes and subsequent consultation notes in each of the two discipline groups with only a few criteria on the PAT found to be satisfactorily recorded. The most significant gaps identified in case notes taken during students' subsequent consultations with patients in each discipline. Conclusion: A tool for assessing student's case records emerged from the study. The Record Keeping Audit Tool (RKAT) will be trialled in further research, the next phase of which will be to transform the RKAT to an online tool to allow ease of administration so that larger data samples can be collected. This work will concentrate on developing a validity argument for the RKAT.

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