Table 1 Percentages of complete documentation in each section of simulated charts
From: Assessing medical student documentation using simulated charts in emergency medicine
Section | Complete (%) |
|---|---|
History of present illness | |
Location | 103 (100%) |
Quality | 67 (64.4%) |
Severity | 91 (87.5%) |
Duration | 72 (69.2%) |
Timing | 53 (50.1%) |
Context | 22 (21.1%) |
Modifying factors | 43 (41.3%) |
Associated signs and symptoms | 5 (4.8%) |
Review of systems | |
Problem Focused (0) | 8 (7.6%) |
Expanded Problem (1) | 14 (13.4%) |
Detailed (2–9) | 81 (77.8%) |
Comprehensive (≥10) | 0 (0%) |
Past medical, family, social history | |
Past Medical History | 82 (78.8%) |
Family History | 2 (1.9%) |
Social History | 20 (19.2%) |
Physical exam | |
Limited exam of affected Body Area or Organ System (1) | 8 (7.6%) |
Limited exam of affected Body Area(s) and other related organ system (2–4) | 44 (42.3%) |
Extended exam of Body Area(s) and other symptomatic related Organ System(s) (5–7) | 41 (39.7%) |
General multi-system exam or complete single Organ System exam (≥8) | 10 (9.6%) |