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Essential for clinical reasoning and patient safety: the accuracy of clinical records. a swedish example

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11:30 am

27 February 2024

Exhibition Hall (Poster 1)

Simulated, clinical and virtual environments for assessment

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Presentation Description

Nikolaos Christidis1
Viveca Lindberg2 and Maria Christidis3,4
1 Karolinska Institutet, Department of Dental Medicine
2 Stockholm University
3 The Swedish Red Cross University, Department of Health Sciences
4 Karolinska Institutet, Department of Neurobiology, Care Sciences and Society




Background:
Clinical records create the basis for clinical reasoning, diagnostics, treatment planning, as well as for the outcome of the treatment (1). Therefore, the aim of this study was to explore clinical protocols of last year dental students to find patterns of adequate and inadequate content. 

Summary of work:
Thirty-three clinical protocols that comprised patient history, clinical findings, treatment planning, an evidence-based reflection of diagnostics/causalities/treatments/prognostics, and epicrisis were collected. The protocols were subject to thematic analysis (2). 

Results:
Only one of 33 protocols was acceptable in its original form. Most common inadequacies concerned descriptions of a) patient-complaints regarding localization, pain/headache characteristics, jaw-dysfunctions, factors affecting complaints, and on general health; and b) findings related to the clinical examination. Further, these inadequacies resulted in inaccurate diagnostics, treatment approaches presented in their reflection. Finally, students had difficulties providing adequate/relevant references to the statements in their reflection. 

Discussion:
The inaccuracies and inadequacies points to an imminent risk for patient-safety. Incomplete information may lead to incorrect diagnoses and in turn to inappropriate or wrong treatment-approaches (1). This study emphasizes the challenges professional higher education faces to give students opportunities to integrate academic and professional texts, ensuring that health professionals can produce high-quality clinical notes (3). 

Conclusions:
Dental students in their last year of education have difficulties to correctly reproduce and describe what patients say and what students observe in their clinical examination. A second challenge for the students is to integrate academic content in a professional context, in this case in terms of relevant references for their clinical reflection. 

Take-home messages:
This study emphasizes the need to develop teaching in professional higher education regarding literacy practices. Students need to be given opportunities to train their writing in relation to what they hear and to what they observe, and to integrate academic texts to professional contexts. 


References (maximum three) 

1. Jorunn B, Victor V, Mari OR. Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students. Front Comput Sci. 2021(01 June 2021). 

2. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative research in psychology. 2021;18(3):328-52. 

3. Lindberg V, Jounger SL, Christidis M, Christidis N. Literacy as part of professional knowing in a Swedish dental education. BMC Med Educ. 2021;21(1):373. 

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