Effectiveness of Electronic Teaching of Patient Charting Among Internal Medicine Residents at Masih Daneshvari Hospital

Medicine involves a logic (heuristic), in which a collection of information and experience comes together; as such, teaching medicine is not an easy task. This study was planned to evaluate new ways of teaching effective patient charting for medical residents that is personalised and intended to be interactive.

This study was prospective and observational study. To achieve this goal, all residents in the Internal Medicine Residency during months of January–March 2011 were encouraged to participate. Data source was patient Progress Note sheet, which included important clinical information and assessment and plans regarding patient care. Progress notes and admission orders were randomly evaluated in patient charts to obtain number appropriate for observational study report. One physician performed all chart reviews. E-mails of all participant residents were recorded and patient progress note was evaluated in three steps to improve quality of care. Evaluation of progress note and orders were E-mailed to residents.

In this study, residents overall did very well on charting progress notes and admission orders for the patients. Admission diagnosis and incomplete report of vital signs were most commonly missing from progress notes. Control of vital signs and range to call physician in the section on nursing orders were most commonly missing in admission orders. A few of the orders were not timed. The E-mailed evaluation notes led to discussions on wards regarding complete note writing.

Method of teaching residents in wards often include attending rounds, interactive sessions and resident rounds, which are not effective methods to evaluate progress of residents regarding all aspects of medical care such as patient charting. As a result, we chose to use E-learning method for patient charting evaluation and teaching. Discussion about charting was promoted between house staff.