Informatics in Medicine Unlocked (Jan 2024)
Designing and evaluating a web-based training program for medical record documentation: Insights from a developing country experience
Abstract
Background: The quality of medical documentation is crucial for enhancing patient care, as accurate records reduce medical errors and improve patient safety. Given the pivotal role of medical records in delivering high-quality healthcare services, effective training in documentation skills is essential. Whence, this study aimed to design and evaluate a web-based training program focused on medical record documentation, specifically for medical students in Iran (West Azerbaijan province, Urmia), but can be easily adapted to other pertinent cases. Method: This semi-experimental study was conducted in 2023 and comprised three main phases: pre-intervention, intervention, and post-intervention. In the first phase, an online questionnaire assessing knowledge, attitudes, and performance was developed and integrated into the web-based education program. During the second phase, multimedia electronic content was created and made accessible to students for two months. In the final phase, the same online questionnaire was administered to the students again. The study involved 114 medical students from Urmia University of Medical Sciences. Among the 114 medical students (61 externs and 53 interns), 53.4 % were male, and 46.6 % were female. The data were analyzed using SPSS 16 software. Results: Following the intervention, students’ knowledge scores are seen increase from 76.50 to 86.30, attitudes improved from 79.33 to 85, and performance enhanced from 74.92 to 81.40. Further statistical analysis reveals that the web-based training significantly impacted the knowledge, attitudes, and performance of the medical students regarding documentation, with a p-value less than 0.05. Conclusion: The findings of this specific study indicate that web-based education, supplemented with multimedia content, has led to significant improvements in the knowledge, attitudes, and performance of medical students in medical record documentation. While these positive outcomes suggest that the course characteristics played an important role, further investigation is no doubt needed to establish a direct causal relationship. Ongoing studies are surely recommendable. Nonetheless, implementing such educational approaches appears to be an essential ingredient for enhancing the documentation skills of future healthcare professionals. The study may open educational perspectives and inspire further ad hoc research in nearby domains making use of complex documentation.
