Research Information System
HEALTH INFORMATION MANAGEMENT JOURNAL, 2025 (SCI-Expanded)
Background: Proper clinical record-keeping is critical for effective communication, quality control and legal compliance in health care. Despite its importance, studies indicate that physicians often lack adequate documentation skills. Current medical curricula primarily address these skills during clinical years, leaving pre-clinical students underprepared.Objective: This study aims to describe the implementation of a clinical record-keeping training program for pre-clinical medical students and evaluate its outcomes.Method: This experimental study had a non-randomised controlled pre- and post-test design. The study involved implementing a 12-week training program for pre-clinical students, consisting of lectures and standardised patient interviews. A control group of students who received only the traditional curriculum was included for comparison. Pre-test and post-test assessments were conducted, and student satisfaction with the program was evaluated through a questionnaire.Results: Results indicated a significant improvement in clinical record-keeping scores among students who received the new training program compared to the control group. Student satisfaction with the program was also positive.Conclusion: Results demonstrated that early clinical record-keeping training significantly enhanced the skills and preparedness of pre-clinical students for their clinical years and eventual professional practice. Initiating such training during the pre-clinical phase is crucial for ensuring the development of competencies essential for effective healthcare delivery.Implications for health information management practice: Introducing structured record-keeping education before clinical exposure can bridge skill gaps early, foster better documentation habits, and ultimately improve the quality of health information management across healthcare systems. This strategy may also lead to improved clinical efficiency and patient care quality in the long term.