Medicons: Toward clinical examination diagrams standardization in medical documentation

Abstract

Background: Electronic patient records (EPRs) allow efficient and accurate medical documen-tation. 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.