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

Moore, K; Vaughan, B; Cox, A

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

Moore, K Vaughan, B

Cox, A

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Publisher:: ELSEVIER SCI LTD
Publication Type:: Journal Article
Citation:: International Journal of Osteopathic Medicine, 2017, 24, pp. 37-41
Issue Date:: 2017-06-01

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Field	Value	Language
dc.contributor.author	Moore, K
dc.contributor.author	Vaughan, B https://orcid.org/0000-0002-8623-4558
dc.contributor.author	Cox, A
dc.date.accessioned	2022-10-04T03:27:46Z
dc.date.available	2022-10-04T03:27:46Z
dc.date.issued	2017-06-01
dc.identifier.citation	International Journal of Osteopathic Medicine, 2017, 24, pp. 37-41
dc.identifier.issn	1746-0689
dc.identifier.issn	1878-0164
dc.identifier.uri	http://hdl.handle.net/10453/162285
dc.description.abstract	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.
dc.language	English
dc.publisher	ELSEVIER SCI LTD
dc.relation.ispartof	International Journal of Osteopathic Medicine
dc.relation.isbasedon	10.1016/j.ijosm.2016.07.003
dc.rights	info:eu-repo/semantics/closedAccess
dc.subject	1104 Complementary and Alternative Medicine
dc.subject.classification	Orthopedics
dc.title	A pilot study to develop a tool for the assessment of students' clinical record keeping
dc.type	Journal Article
utslib.citation.volume	24
utslib.for	1104 Complementary and Alternative Medicine
pubs.organisational-group	/University of Technology Sydney
pubs.organisational-group	/University of Technology Sydney/Faculty of Health
pubs.organisational-group	/University of Technology Sydney/Faculty of Health/Public Health
utslib.copyright.status	closed_access	*
dc.date.updated	2022-10-04T03:27:45Z
pubs.publication-status	Published
pubs.volume	24

Abstract:

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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http://hdl.handle.net/10453/162285