Orthopedic residents require greater instruction on the clinical examination and documentation of spine pathology, according to a study in The Spine Journal.
Here are four things to know:
1. An objective structured clinical examination was conducted for 13 orthopedic post-graduate year-1 intern residents at a major orthopedic specialty hospital and academic center to assess the progress of their skills in performing a history, physical examination and documentation of the encounter for a standardized patient with spinal stenosis.
2. The examination followed a month-long boot camp that included communications skills and instruction in performing a history and physical examination. Interns were scored based on their performance of the physical examination, communication skills, completeness and accuracy of their EMR and their diagnostic conclusions from the patient encounter.
3. Nine of the 13 interns — 69.2 percent — documented at least one finding that was not assessed or tested in the encounter, and four of the 13 interns — 30.8 percent — included inaccuracies in the medical record. Communication skills with the patient failed to meet expectations. Interns tended to overscore themselves, especially on their performance on the physical examination.
4. The study authors claim these findings support a need for greater systemic support for improving resident documentation through comprehensive education and evaluation modules; these findings can be used to develop a standardized curriculum for documenting patient encounters.
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