Trainer – Registrar Education and Assessment Toolkit

What do you want to do with your registrar today?

TREAT

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I want to assess the registrars documentation in the medical record

 

Use the Medical Record Review Tool

What is it?

This is a checklist of what should appear in a paper or electronic medical record for it to be satisfactory. It looks at a single entry and entries in general.

Who developed it?

This has been adapted by NTGPE from the General Medical Council in the UK performance procedures. It is published in the GPET ADT guide.

How is it done?

A random selection of the registrar’s medical records can be compared with the checklist.

What does the supervisor do?

The supervisor can discuss with the registrar the implications of not completing the medical record satisfactorily  - it may be that the registrar has carried out appropriate activities in the consultation and not documented them, or that they have not been done.

Practice tips

Use the checklist (or certain parts of it) to confirm the difference between what gets written in the medical record and our consulting skills to get the information and the unwritten information we hold in our heads.

Further Information

Medical Education 35: Suppl. 19-19 2001

Or contact Tim Senior