Are self-reported patient encounter data accurate?

Abstract

Medical education programs are using Personal Digital Assistants (PDA’s) to facilitate the recording of encounters between students and patients during clinical rotations. Wichita State University Physician Assistant Program (WSU-PA) uses PDA’s to track clinical patient encounters during its clinical year. The WSU-PA clinical rotation at Pratt Regional Medical Center Emergency Department (PRMC-ED) provided an opportunity for a comparison of medical records and PDA entries made by students who spent 4 to 6 weeks at that site. The purpose of this study was to verify the self-reported data submitted by students with the actual documentation on the medical record and identify any significant inconsistencies. WSU-PA students submitted data of all patient encounters at PRMC-ED which were subsequently compared to data obtained through review of medical records for patients seen by the student. The age and sex of the patient as well as the diagnosis of each visit were compared for consistency using HandEchart® PDA software and Microsoft Excel® spreadsheets. Of reported diagnoses, 32.16% matched the medical records, 24.69% of patient ages matched the medical records, and 31.18% of patient gender matched the medical records. In conclusion, data revealed an inconsistency between medical charts and PDA entries of patient encounters during clinical rotations at PRMC-ED. The data that represented the age, sex, and diagnosis of patients encountered in clinical rotations by 2nd year PA students was consistent 1/3 of the time.