Akademik Veri Yönetim Sistemi
KONURALP TIP DERGISI, cilt.15, sa.2, ss.257-265, 2023 (ESCI)
Objective: In relation to clinic record keeping, we aimed to determine the need in the undergraduate education at our university and propose a program recommendation regarding the content of the training program to be implemented based on the needs analysis. Methods: Qualitative descriptive research method was used. To determine clinical record keeping education needs, interviews were conducted with 10 faculty members working at the Faculty of Medicine in the 2022-2023 academic year, using a semi-structured form. In addition, a 17question survey was administered to elicit the needs of the students attending the Faculty of Medicine. Results: A total of 102 students participated in the study. Eighty-two (80.4%) students reported not having received any education on clinical record keeping. For the questions scored on a sevenpoint Likert scale, related to “how sufficient do you consider the clinical records you keep?” and “how comfortable do you feel when writing patient notes?”, the mean scores were calculated to be 3.89±1.66 and 3.55±1.74, respectively. Ninety-two (90.2%) students considered it necessary to take a course on how to keep clinical records. Ten faculty members participated in the interviews conducted using a semi-structured form. During these interviews, emerging themes concerning the quality of clinical records were the comprehensiveness and usefulness of these records, and the use of appropriate language. When questioning the reasons for deficiencies in clinic record keeping, issues within the education system and, predominantly, a lack of training have come to the forefront. Our main guiding topics that could serve as references for the training programs to be conducted are the format, content, writing, and legal responsibilities arising from the records. Conclusions: We identified the deficiencies and needs related to clinical record keeping in our faculty. Based on our results, we consider that the implementation of appropriate curricula and activities will increase the quality of clinical records.