Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations

Emre Emekli; Özlem Coşkun; Işıl İrem Budakoğlu; Yavuz Selim Kıyak

Makale detayları

Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations

Yazarlar:

Emre Emekli | Özlem Coşkun | Işıl İrem Budakoğlu | Yavuz Selim Kıyak

Yayıncı:

Duzce University

Ana Başlıklar:

Health Care Administration

Dergi:

Konuralp Medical Journal Vol.15 Issue 2, pp.257-265

Belge Tipi:

Makale

Yayın Tarihi:

6/2023

Belge Dili:

İngilizce

Document ID (Org No.):

2001292049

pISSN:

1309-3878

Anahtar kelimeler:

Özet:

 Objective: To determine the need for clinical record keeping education in undergraduate programs at our university. Methods: Qualitative descriptive research method was used. To determine clinical record keeping education needs, interviews were conducted with 10 faculty members working at the Faculty of Medicine in the 2022-2023 academic year, using a semi-structured form. In addition, a 17-question survey was administered to elicit the needs of the students attending the Faculty of Medicine. Results: A total of 102 students participated in the study. Eighty-two 80.4 students reported not having received any education on clinical record keeping. For the questions scored on a seven-point Likert scale, related to how competent they considered themselves to be in clinical record keeping and how comfortable they felt while writing patient notes, the mean scores were calculated to be 3.891.66 and 3.551.74, respectively. Ninety-two 90.2 students considered it necessary to take a course on how to keep clinical records. Ten faculty members participated in the interviews conducted using a semi-structured form. During these interviews, emerging themes concerning the quality of clinical records were the comprehensiveness and usefulness of these records, and the use of appropriate language. When the reasons for deficiencies in clinical record keeping were questioned, problems in the education system and a lack of education were prominent. Conclusion: We identified the deficiencies and needs related to clinical record keeping in our faculty. Based on our results, we consider that the implementation of appropriate curricula and activities will increase the quality of clinical records.

 Objective: To determine the need for clinical record keeping education in undergraduate programs at our university. Methods: Qualitative descriptive research method was used. To determine clinical record keeping education needs, interviews were conducted with 10 faculty members working at the Faculty of Medicine in the 2022-2023 academic year, using a semi-structured form. In addition, a 17-question survey was administered to elicit the needs of the students attending the Faculty of Medicine. Results: A total of 102 students participated in the study. Eighty-two 80.4 students reported not having received any education on clinical record keeping. For the questions scored on a seven-point Likert scale, related to how competent they considered themselves to be in clinical record keeping and how comfortable they felt while writing patient notes, the mean scores were calculated to be 3.891.66 and 3.551.74, respectively. Ninety-two 90.2 students considered it necessary to take a course on how to keep clinical records. Ten faculty members participated in the interviews conducted using a semi-structured form. During these interviews, emerging themes concerning the quality of clinical records were the comprehensiveness and usefulness of these records, and the use of appropriate language. When the reasons for deficiencies in clinical record keeping were questioned, problems in the education system and a lack of education were prominent. Conclusion: We identified the deficiencies and needs related to clinical record keeping in our faculty. Based on our results, we consider that the implementation of appropriate curricula and activities will increase the quality of clinical records.

 Objective: To determine the need for clinical record keeping education in undergraduate programs at our university. Methods: Qualitative descriptive research method was used. To determine clinical record keeping education needs, interviews were conducted with 10 faculty members working at the Faculty of Medicine in the 2022-2023 academic year, using a semi-structured form. In addition, a 17-question survey was administered to elicit the needs of the students attending the Faculty of Medicine. Results: A total of 102 students participated in the study. Eighty-two 80.4 students reported not having received any education on clinical record keeping. For the questions scored on a seven-point Likert scale, related to how competent they considered themselves to be in clinical record keeping and how comfortable they felt while writing patient notes, the mean scores were calculated to be 3.891.66 and 3.551.74, respectively. Ninety-two 90.2 students considered it necessary to take a course on how to keep clinical records. Ten faculty members participated in the interviews conducted using a semi-structured form. During these interviews, emerging themes concerning the quality of clinical records were the comprehensiveness and usefulness of these records, and the use of appropriate language. When the reasons for deficiencies in clinical record keeping were questioned, problems in the education system and a lack of education were prominent. Conclusion: We identified the deficiencies and needs related to clinical record keeping in our faculty. Based on our results, we consider that the implementation of appropriate curricula and activities will increase the quality of clinical records.

 Amaç: Klinik kayıt tutma ile ilgili olarak üniversitemizde lisans eğitimindeki ihtiyacı belirlemeyi ve ihtiyaç analizi sonucuna göre uygulanacak eğitim programının içeriğinde hangi konuların yer alması gerektiğine dair bir program önerisi sunmayı amaçladık. Metod: Çalışmamız nitel araştırma türünde olup betimsel araştırma yöntemi kullanılmıştır. Klinik kayıt tutma eğitimi ihtiyacını belirlemek için 2022-2023 eğitim öğretim yılında Tıp Fakültesinde görevli 10 öğretim üyesi ile yarı-yapılandırılmış form aracılığıyla görüşmeler gerçekleştirilmiştir. Ayrıca Tıp Fakültesi öğrencilerinin ihtiyaçları belirlemek için 17 soruluk anket formu kullanılmıştır. Bulgular: Çalışmaya 102 öğrenci katıldı. Katılımcıların 82si 80.4 klinik kayıt tutma ile ilgili eğitim almadığını belirtti. 7li Likert tipi ölçekle değerlendirilen tuttuğunuz kayıtları ne kadar yeterli görüyorsunuz ve hasta notu yazarken kendinizi ne kadar rahat hissediyorsunuz sorularına verilen cevapların puanları ise sırasıyla 3.891.66 ve 3.551.74 olarak hesaplandı. Öğrencilerin 92 90.2si klinik kayıt tutmanın nasıl olması gerektiği ile ilgili ders almanın gerekli olduğunu düşünmekteydi. Yarı-yapılandırılmış formla yaptığımız görüşmelere 10 öğretim üyesi katıldı. Görüşmelerde klinik kayıtların niteliği ile ilgili olarak klinik kayıtların kapsamlı olması, kullanışlı olması, uygun dil kullanılması gibi temalar ön plana çıkmıştır. Klinik kayıt tutma açısından eksikliklerin sebepleri sorgulandığında eğitim sistemi sorunları ve yoğunlukla birlikte eğitim eksikliği ön plana çıkmıştır. Yapılacak eğitimler için birer yol gösterici olabilecek başlıklarımız kayıtların formatı, içeriği, yazımı ve kayıtlardan doğan hukuki sorumluluk olarak çalışmamızda öne çıkmıştır. Sonuç: Fakültemizde klinik kayıtlar konusundaki eksiklik ve ihtiyaçları belirlediğimizi, ilerde buna uygun eğitim öğretim faaliyetlerinin gerçekleştirilmesinin klinik kayıtların niteliğini artıracağını düşünmekteyiz.

Makale detayları

Clinical Record Keeping Education Needs in A Medical School and The Quality of Clinical Documentations

Yazarlar:

Emre Emekli | Özlem Coşkun | Işıl İrem Budakoğlu | Yavuz Selim Kıyak

Yayıncı:

Duzce University

Ana Başlıklar:

Health Care Administration

Dergi:

Konuralp Medical Journal Vol.15 Issue 2, pp.257-265

Belge Tipi:

Makale

Yayın Tarihi:

6/2023

Belge Dili:

İngilizce

Document ID (Org No.):

2001292049

pISSN:

1309-3878

medical documentation

clinical records

needs analysis

medical educationtıbbi dokümantasyon

klinik kayıt

ihtiyaç analizi

tıp eğitimi

Sayı

Makale detayları

Yazarlar: Emre Emekli | Özlem Coşkun | Işıl İrem Budakoğlu | Yavuz Selim Kıyak

Yayıncı: Duzce University

Ana Başlıklar: Health Care Administration

Dergi: Konuralp Medical Journal Vol.15 Issue 2, pp.257-265

Belge Tipi: Makale

Yayın Tarihi: 6/2023

Belge Dili: İngilizce

Document ID (Org No.): 2001292049

pISSN: 1309-3878

Sayı

Yazarlar:

Emre Emekli | Özlem Coşkun | Işıl İrem Budakoğlu | Yavuz Selim Kıyak

Yayıncı:

Duzce University

Ana Başlıklar:

Health Care Administration

Dergi:

Konuralp Medical Journal Vol.15 Issue 2, pp.257-265

Belge Tipi:

Makale

Yayın Tarihi:

6/2023

Belge Dili:

İngilizce

Document ID (Org No.):

2001292049

pISSN:

1309-3878