Development and validation of standardized clinical summary format.

Background: The use of a structured guideline in medical education to reach a diagnosis provides accurate information which is relatively free from bias. The purpose of this paper is to assess the performance of medical students using unstructured and structured format in case summary.

Methods: One hundred and sixty- nine medical students in Part III MB; BS Programme in the University of Port Harcourt were studied. There were 83 students in Paediatics [SP] and 86 students in Obstetrics and Gynaecology [SOG] postings. The students had video recorded presentation of three clinical cases comprising of two paediatrics [PC1&PC2] and one surgical case [SC3]. The summary for the first case [PC1] was done using an unstructured format, while the second case [PC2] was done with both unstructured PC2a and structured PC2b format. The Surgical case [SC3] was done using only the structured format. The discrete pieces of important information in each case were quantified and scored by trained assessors. PC1and SC3 had a total of 16 points each while PC2 had a total of 24 points.

Result: The pre-exposed SOG students scored significantly higher than none-exposed SPG students in PC1 and SC3; P<0.05. In PC2 75.1% students scored above 12 points using structured summary format compared to 38.5% students with unstructured format , P<0.05. The students had significantly higher score using structured format in SC3 than PC1.

Conclusion: The use of structured summary format enabled better case summary than unstructured format, and it's transferable across different departments.