Abstract:

Introduction:
The writing of medical records is a basic skill in the training of doctors on which adequate and effective patient care depends, minimising risks and discomfort. In addition, the medical record has legal, epidemiological and care implications, so there is a need to analyse the extent to which medical students adequately record patient information.
The main objective of the study was to determine the degree of concordance between the information obtained in a patient interview and that recorded in the clinical history taken by 5th year medical students. Likewise, we tried to analyse the anamnesis, physical examination and clinical judgement items recorded in the history written by the students, and whether the discordant data were due to excess or deficiency, thus assessing the quality of the clinical history.

Methodology:
Retrospective cross-sectional descriptive observational study of a standardised patient encounter and the subsequent drafting of the patient's clinical history. It was conducted on a sample of 112 5th year medical students who attended the clinical simulation scenario between 9 and 16 September 2022. The evaluators were the teachers who designed the clinical case and the standardised patients interviewed. The medical record was checked for 60 items of anamnesis, physical examination and clinical judgement by cross-checking the students' video recordings, and two additional items of writing quality were assessed. Each item was described by absolute and relative frequencies. For statistical analysis, R v 4.1 software was used.

Results:
A concordant result means both that the student asks that item in their interview and reflects it correctly in the medical record and that when they do not ask it but do not reflect it either. A successful result corresponds to items that are correctly asked and correctly written in the medical record. The most concordant competence domains were clinical judgement with 94.1%, followed by anamnesis with 88%. The domains with the highest percentage of correct answers were anamnesis with 58% and clinical judgement with 57.6%. Among the domains with the highest percentage of correct answers, the most important items were "location of pain" (99.1%), "onset of pain" (98.2%), "presence of dyslipidaemia" (96.3%). On the other hand, among the items that the students do not ask about in the clinical interview but which they do reflect in the medical history, the most important are the "performance of Rovsing's sign" in 27.7% of the students, and abdominal auscultation in 10.7%.

Conclusion:
The degree of concordance between interview and clinical history is high. However, there is information that is not concordant either because it is asked and is not collected or is collected erroneously in the clinical history, or because it appears in the clinical history without having been asked. This study will help the student to improve the clinical interview and make it consistent with the clinical history.

Keywords:

Clinical interview, medical history, concordance.