Patient-encounter log forms, whether card-, computer-, or paper-based, have been used for decades to document diagnoses seen and patient demographics.1 They provide data that allow medical school programs to decide where to place students,2 to document clinical experiences,3 to adjust curricula and determine the need for supplemental teaching,4 to compare clinical experiences at different sites,4 to determine gaps in educational experiences,5 and to keep preceptors and students attentive to areas where they are receiving inadequate clinical experiences.5
Typically, log forms have been expensive or time-consuming to analyze. Johnson and Michener were able to extract the patient-encounter information from an integrated computerized tracking system using ICD-9 billing codes,6 and Snell et al. successfully employed optical-scan encounter forms.4 However, these methods, while allowing for more rapid analysis, are expensive to establish and maintain. At the University of Hawaii John A. Burns School of Medicine, a simple one-page log form was developed and used by third-year medical students in a family medicine clerkship. This form costs very little to use or analyze and provides immediate information to students, preceptors, and the clerkship coordinator about the students' range of patient-care experiences.
THE LOG FORM AND ITS IMPLEMENTATION
The original log form listed the most common ambulatory care diagnoses seen in the United States with demographic categories for gender, age range, and follow-up status.7 Students recorded patient data for each encounter by entering hash marks on the form in the appropriate areas (one for each diagnosis and demographic category). The information was entered into a database by the administrative assistant. By quickly glancing at the form, teachers and students could see the areas in which the students had had little or no experience.
The form was first tested during a seven-week required ambulatory family medicine clerkship for third-year medical students during the 1998–99 academic year. The clerkship required 140 hours of clinical time and 50 hours of didactic sessions. In order to receive course credit, students were required to document information about all patients they cared for and to submit the completed log forms on the last day of the clerkship. Log forms were reviewed at the mid-block site visit and during weekly conferences. If students were missing areas of clinical experience, preceptors were informed and clinical experience were supplemented at alternative sites if necessary. Data entry by the administrative assistant onto an Excel spreadsheet required approximately three minutes per student per week. At the end of the school year, preceptors were provided with information about how patient-log data from their sites compared with the average patient-log data. Students were surveyed at the end of the school year regarding their use of the patient-log forms and how it had affected their learning experiences.
During the ten-month implementation period, all 44 students in the clerkship completed the forms. On the rotation evaluation completed by all students, the ease of keeping patient logs was rated 3.7 on a five-point Likert scale, with 5 being the easiest. Twelve of the 44 students also completed a year-end survey. On this form, the students estimated that they had missed recording an average of 27% of the patient encounters and that it took between 10 seconds and two minutes to complete the log form for each patient (an average of 57 seconds). Survey results indicated that the students felt the log forms had no effect on preceptors' teaching, and there was no clear consensus among the students about whether patient logs improved the range of patients seen, influenced the choice of patients seen, or improved the educational experience.
Accuracy of the data obtained from the log forms was assessed by comparison with patient-log data previously documented by others. Rosenblatt et al. reported that their students recorded having seen patients in only 54% of all possible diagnostic categories.9 Johnson and Michener reported that only one patient encounter a day went unrecorded with their computerized recording system.6 Bentsen found that residents recorded only 62% of diagnoses as judged by observers.10 Our students estimated that they recorded 73% of patient encounters. Furthermore, on the log forms, the students recorded gender data for only 73% of the patients for whom they recorded age-range data. Clearly, one of the limitations of this system is its dependence upon the diligence of students and the monitoring of faculty.
Still, the form has helped our family medicine clerkship to document the consistency of students' clinical experiences and to improve or supplement them as needed. After ten months of using the original patient-log forms, three changes were made to improve the form and make it more representative of the standard experience on our clerkship. First, diagnoses are now presented in descending order of frequency at our site; second, the form now includes Pap tests and well-child checks as procedures; and, third, based upon the results from the first year of use, and recommendations from the literature,8 diagnostic categories were clustered or adjusted to include the following: the category of viral warts was eliminated; joint disorders replaced degenerative joint disease; sprains and strains were combined with fractures and dislocations to create one category; nonfungal infection of the skin was expanded to skin infection, fungal or nonfungal; ulcerations and skin breakdown were added to the lacerations, contusions, and abrasions category; pregnancy care and abortion were combined with contraception to create a new category, pregnancy and family planning, and vaginitis was expanded to pelvic disorders. After a second year of use, minimum requirements for clinical experiences were added to the diagnosis categories, and computer-based self-assessment tests were developed for the top ten diagnoses. The patient-log form representing the clinical requirements and the competency surveys are currently disk-based and are downloaded weekly via e-mail. However, they will be programmed into personal digital assistants for students to utilize on the clerkship. This will allow us to document students' clinical experiences and compliance with clinical requirements, as well as completion of competency testing for our most common diagnoses.
Although the log form is designed for use in a family medicine clerkship, it could easily be adjusted for use in other clerkships, clinical experiences, or specialties. Use of personal digital assistants to record clinical experiences will undoubtedly increase compliance and decrease staff and student time spent processing data.
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