Assessment of junior doctors' admission notes: do they follow what they learn?

Objectives: To assess the completeness of history-taking and physical-examination notes of junior doctors at King Abdulaziz University Hospital per the approach they learned in medical school.

Methods: In this retrospective study, we reviewed 860 admission notes written by 269 junior doctors (interns and residents) in an academic tertiary-care medical centre in Jeddah, Saudi Arabia, over a two-month period. Notes were evaluated for completeness using a checklist developed with reference to relevant medical textbooks.