Bir Tıp Fakültesinde Klinik Kayıt Tutma Eğitimindeki İhtiyacı Belirlemeye ve Klinik Kayıtlar Niteliği Üzerine Bir Çalışma

Objective: To determine the need for clinical record keeping education in undergraduate programs at our university. 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 17-question 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 seven-point Likert scale, related to how competent they considered themselves to be in clinical record keeping and how comfortable they felt while 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 the reasons for deficiencies in clinical record keeping were questioned, problems in the education system and a lack of education were prominent. Conclusion: 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.