Medicons: toward clinical examination diagrams standardization in medical documentation

摘要

Background: Electronic patient records (EPRs) allow efficient and accurate medical documentation. Diagrams have traditionally been used to document clinical signs in patient notes. The interpretation of these diagrams may vary among doctors across a range of specialties, but this has never been tested previously. This study investigated how common diagrams were interpreted and explored the use of digitalized diagrams – Medicons in creating a common language to be used in digital clinical examination proformas. Materials and methods: A cross-sectional survey utilizing a multiple-choice questionnaire was carried out across London hospitals. Seventeen digitalized examination diagrams were included in a multiple-choice questionnaire to test doctors’ perception and explore their opinions of diagram usage. The questionnaire was sent to junior doctors in training. Results: A total of 206 responses were received from 31 foundation year 1 trainees, 45 foundation year 2 trainees, 94 core surgical trainees and 36 core medical trainees. Diagrams were interpreted correctly, on average, 75% of the time. The majority of doctors (94%) felt that diagrams facilitated the understanding of clinical examination, documentation of pathologic site (98%) and improved the efficiency of documentation (89.8%). All doctors felt that diagrams may benefit overall medical care provision. Conclusion: Digitalizing signs and symptoms in EPR will enhance clinical documentation and may contribute to better patient care. New initiatives need to be employed to increase the use of diagrams – Medicons, as young doctors perceived these to improve clinical documentation. Standardized electronic proformas should be included into EPR to improve the efficiency and accuracy of clinical examination documentation.