TY - JOUR T1 - Assessment of junior doctors’ admission notes: do they follow what they learn? AU - Barnawi, R.A. AU - Ghurab, A.M. AU - Balubaid, H.K. AU - Alfaer, S.S. AU - Hanbazazah, K.A. AU - Bukhari, M.F. AU - Hamed, O.A. AU - Bakhsh, T.M. KW - admission notes assessment KW - history-taking KW - junior doctors KW - admission notes completeness KW - physical examination KW - saudi arabia KW - PY - 2017/03/11 Y1 - 2017/02/25 VL - 8 N1 - doi: 10.5116/ijme.58b1.4d7e DO - 10.5116/ijme.58b1.4d7e M3 - doi: 10.5116/ijme.58b1.4d7e JO - Int J Med Educ SP - 79 EP - 87 PB - IJME SN - 2042-6372 UR - http://www.ijme.net/archive/8/assessment-of-junior-doctors-admission-notes/ L1 - http://www.ijme.net/archive/8/assessment-of-junior-doctors-admission-notes.pdf N2 - Objectives: To assess the completeness of history-taking and physical-examination notes of junior doctors at King Abdulaziz University Hospital per the approach they learned in medical school. Methods: In this retrospective study, we reviewed 860 admission notes written by 269 junior doctors (interns and residents) in an academic tertiary-care medical centre in Jeddah, Saudi Arabia, over a two-month period. Notes were evaluated for completeness using a checklist developed with reference to relevant medical textbooks. The checklist included 32 items related to history-taking and physical examination. Based on the review of the notes, checklist items were evaluated as complete, incomplete, not present, or not applicable according to set criteria. Data were analysed and summarised for information on the frequency and relative frequency of these types. Results: The history items varied in completeness. At the high end, asking about chief complaint and duration, associated symptoms, aggravating and relieving factors, and conducting systemic review were marked ‘complete’ in 74.2%, 81.7%, 80.4%, and 79.7% of notes, respectively. At the low end, asking about previous episodes, allergies, medications, and family history were complete in 5.3%, 1.9%, 4.8%, and 2.9% of notes, respectively. All physical examination items were poorly documented, especially breast examination, which was ‘not present’ in 95.8% of the notes. Conclusions: Junior doctors’ history and physical-examination notes are often incomplete and do not follow the approach taught in medical school. The reasons for this must be studied via focus-group discussions with junior doctors. ER -