Measuring medical residents' chart-documentation practices.

  title={Measuring medical residents' chart-documentation practices.},
  author={Marguerite T. Moran and Thomas H. Wiser and Joy Nanda and Hyman Gross},
  journal={Journal of medical education},
  volume={63 11},
To determine the adequacy of medical history documentation, investigators videotaped 26 clinical interviews performed by medical residents in ambulatory practice, and the contents of each videotape were compared with the corresponding entries in the medical record. The residents recorded a little over half of all medical history information observed on the videotapes. Medical issues were more often documented than psychosocial or health behaviors. The residents in their second postgraduate year… CONTINUE READING
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