Korean Medicine Students’ Medical Record Writing Ability and Its Association with the Related Education

한의과대학 재학생의 진료기록부 작성 현황과 관련 교육과의 연관성

Objectives : We tried to clarify the difficulties the Korean medicine students face when writing medical records, thereby contributing to the development of educational courses on medical record writing. Method : An online-based questionnaire survey was developed by the research team and conducted to 5 medical volunteer groups at 1 Korean medicine college. Results : 89% of the students answered that they had written medical records while volunteering, all of them using paper charts. Students’ knowledge about the medical records and their difficulties in writing them increased altogether according to their academic year. Top 3 difficulties were: (1) writing the medical record while simultaneously communicating with the patient, (2) phrasing the answers in terminology appropriate for medical records, (3) being aware of questions they missed to ask & reviewing the patient’s previous medical records (tied). Conclusion : Students of higher academic year, despite having more knowledge, experienced more difficulties while writing medical records. Their main challenge is in the actual use of the medical records in clinical field.