Background There are many obstacles to contemporaneous record keeping following time-critical clinical events, which may lead to a delay in documentation. We postulated that such delays may create time for reflection that could influence the accuracy of recorded notes.
Objective To observe whether a delay in documenting in patient notes and/or an opportunity to debrief affects the accuracy of note recording.
Methodology University of Sheffield ethical approval was obtained. Final year Student doctors volunteered to participate in controlled simulated acute patient care scenarios. Standardised scenarios (anaphylaxis, cardiac arrest and sepsis) were chosen as appropriate to the level of learning. All scenarios took place in a formal simulation suite, set up as a general Hospital ward. Participants were split into three groups; each which followed a different approach to note keeping. Group 1 received no debrief/time for reflection and were required to make notes immediately after the critical event. Group 2 were debriefed immediately but recorded notes the following day. Group 3 were debriefed and made notes immediately following the event. Note keeping was limited to 10 minutes, with access to simulated patient records, in quiet environment without interruption.
Scenarios were videoed, and the documented notes were subsequently scored for accuracy against the recorded events. This allowed for rating of each student’s performance to address any counfounding that could occur from using different groups with potentially different skills.
Results Note keeping accuracy rates for Groups 1, 2 and 3 were 0.57, 0.63 and 0.69 respectively.
Conclusion There is increased accuracy in patient note recording when the medical professional has the opportunity to immediately debrief and write up notes.
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