Aiming towards chart preparation skill improvements -the usefulness of hands-on learning experiences after the audit of medical records

Shimasaki Akemi, Deguchi Naotaka, Moriuchi Rumiko, Utsumi Hisako, Nomura Chie

doi:10.11191/jhm.10.533

An in-hospital chart audit on 1000 inpatient medical records (186 prepared by residents and 814 by supervising physicians, who have been practicing for over 3 years） was conducted by health information managers at the National Hospital Organization Himeji Medical Center. The physicians' records were valuated based on 20 items. Audit results show that the physicians' records scored on average 14.19±3.26 (out of 20), while charts prepared by residents scored significantly better. The audit also demonstrated that 5.1% of the nurses' records were prepared incorrect. <br>Since 2005, the institution has been holding hands-on learning experience seminars called：'simulation of medical chart disclosure', in order to educate its residents. A supervising physician, whose records needed improvement, was also asked to participate. Attending such seminars has improved medical record-preparation skills significantly. In addition, hands-on learning experience seminars including group discussions were also conducted, using as teaching materials problem records prepared by nurses and others of an incident's case. Based on a survey of participants, results show that these seminars were useful in acknowledging the importance of maintaining appropriate medical records. <br>In conclusion, introducing hands-on learning experience seminars after chart audits is a valued way to improve chart preparation skills.

Aiming towards chart preparation skill improvements -the usefulness of hands-on learning experiences after the audit of medical records

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