Objective: This report describes the implementation and utilization of a comprehensive chart-review tool by a Veteran Affairs chiropractic trainee. The tool was developed to assist student trainees to be efficient and thorough while performing a chart review using the VA electronic health-record system.
Methods: A checklist was designed in a “do-confirm” format using 4 distinct categories: 1) consult, 2) relevant note review, 3) imaging/labs/surgical reports, and 4) cover sheet. Each category contained 2-4 checklist items. The checklist was piloted with a single trainee. Once the checklist was completed in its entirety by the trainee, the supervising chiropractor initiated a clinical discussion using an SBAR (situation, background, assessment, recommendation) communication technique to ensure a thorough understanding of the patient’s case before the evaluation.
Results: Feedback was solicited from the chiropractic trainee following 12 weeks of checklist implementation. The trainees indicated that the tool significantly improved their confidence in engaging in complex case presentations and that the structured approach enhanced their efficiency in processing large volumes of charted medical information.
Conclusion: Our pilot implementation of a comprehensive chart review tool reflects the potential benefit of checklists for improving trainee efficiency and confidence when approaching complex cases. We plan to develop the checklist further and implement it at a wider scale with more trainees.
Author keywords: Chiropractic; Clinical Clerkship; Checklist; Communication
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