Evaluation of the congruence between students' postencounter notes and standardized patients' checklists in a clinical skills examination.

Background And Purpose: Questions remain about the congruence between students' written notes and checklists as summaries of encounters.

Methods: Students examined standardized patients and summarized findings in postencounter notes. The patients completed checklists. A physician read the students' notes and completed parallel checklists to document the history and physical items performed. Rates of under- and overdocumentation were calculated.

Results: Students documented findings for 71% of items performed - an underdocumentation rate of 29%. Approximately 94% of their documented findings were consistent with what they had done. Their rate of overdocumentation was 6%, in which they documented findings inconsistent with the checklists. About half the students had no instances of overdocumentation.

Conclusion: Students' rate of underdocumentation was comparable to experienced clinicians. Although their overdocumentation rate was low overall, it was high for a few students. Evaluation of the congruence between checklists and postencounter notes provides useful information and informs checklist development.