Clinical Record Keeping Education Needs and The Quality of Clinical Documentations

What is it about?

Study conducted at Gazi University's Faculty of Medicine to assess the education needs and perspectives on clinical record keeping among faculty members and students. The study used interviews and surveys to gather data. The results showed that there is a need for structured education on clinical record keeping, as many students had not received sufficient training. Faculty members emphasized the importance of concise and useful records. Deficiencies in clinical records were identified, including missing information, lack of detail, and grammatical issues. Overall, the study highlights the need for improvements in clinical record keeping education and the quality of records. The paper suggests program recommendations to enhance the quality of clinical documentation.

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Photo by Scott Graham on Unsplash

Photo by Scott Graham on Unsplash

Why is it important?

The study revealed that most medical students lacked education on clinical record keeping. Faculty members identified deficiencies in clinical records, emphasizing the need for comprehensiveness and organization. Reasons for deficiencies included a lack of education and issues within the education system. The study emphasized the importance of implementing structured training programs to improve the quality of clinical documentation.