Skip to main content
Proceedings of the AMIA Symposium logoLink to Proceedings of the AMIA Symposium
. 2001:687–690.

Student documentation of multiple diagnoses in family practice patients using a handheld student encounter log.

W Sumner 2nd 1
PMCID: PMC2243664  PMID: 11825273

Abstract

Patient encounter logs may provide an important early opportunity to assess beginning clinical students' attention to and experience with many medical problems. However, there are reasons to doubt the completeness of traditional paper logs. The family practice clerkship at Washington University in St. Louis has tried a series of structured paper and hand held computer logs in search of a format that permits students to completely document their patients' diagnoses. The clerkship introduced a Palm computer log, designed with PumaTech's Satellite forms (R), that uses patient demographics to select a diagnosis entry screen displaying many likely diagnoses as checkboxes. Additional drop lists and combinations of drop lists provide access to less common diagnoses. Students using this log document 2.4 problems per patient on average, and as many as 14 problems in a single patient. Differences between students and preceptors are readily apparent. It is now possible to prepare students to rotate with specific preceptors, and to identify or predict gaps in experience that deserve remedial intervention.

Full text

PDF
687

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Hobbs J., Mongan P. F., Tollison J. W., Miller M. D., Wilson O. R. A decentralized clerkship: strategies for standardizing content and instruction. Fam Med. 1987 Mar-Apr;19(2):133–136. [PubMed] [Google Scholar]
  2. Kowlowitz V., Slatt L. M., Kollisch D. O., Strayhorn G. Monitoring students' clinical experiences during a third-year family medicine clerkship. Acad Med. 1996 Apr;71(4):387–389. doi: 10.1097/00001888-199604000-00018. [DOI] [PubMed] [Google Scholar]
  3. Lustman P. J., Freedland K. E., Griffith L. S., Clouse R. E. Fluoxetine for depression in diabetes: a randomized double-blind placebo-controlled trial. Diabetes Care. 2000 May;23(5):618–623. doi: 10.2337/diacare.23.5.618. [DOI] [PubMed] [Google Scholar]
  4. Rothwell D. J., Cote R. A., Cordeau J. P., Boisvert M. A. Developing a standard data structure for medical language--the SNOMED proposal. Proc Annu Symp Comput Appl Med Care. 1993:695–699. [PMC free article] [PubMed] [Google Scholar]
  5. Snell L. M., Battles J. B., Bedford J. A., Washington E. T. Verifying the curriculum of a family medicine clerkship. Med Educ. 1998 Jul;32(4):370–375. doi: 10.1046/j.1365-2923.1998.00218.x. [DOI] [PubMed] [Google Scholar]
  6. Zinser E. A., Wiegert H. T. Describing learning experiences of undergraduate medical students in rural settings. J Fam Pract. 1976 Jun;3(3):287–291. [PubMed] [Google Scholar]

Articles from Proceedings of the AMIA Symposium are provided here courtesy of American Medical Informatics Association

RESOURCES