{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T10:23:58Z","timestamp":1773311038711,"version":"3.50.1"},"reference-count":42,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2024,3,3]],"date-time":"2024-03-03T00:00:00Z","timestamp":1709424000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["asmepublications.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Clinical Teacher"],"published-print":{"date-parts":[[2024,8]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category\n                      <jats:italic>personal details<\/jats:italic>\n                      overlapped with 94.2% between students' report and ground truth in\u00a0contrast to the main category with the highest discrepancy,\n                      <jats:italic>allergy<\/jats:italic>\n                      , with 41.1% overlap. Pertinent negative items and non\u2010numerical quantifications were often missed.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/tct.13749","type":"journal-article","created":{"date-parts":[[2024,3,4]],"date-time":"2024-03-04T01:54:41Z","timestamp":1709517281000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Lost in translation: Unveiling medical students' untold errors of medical history documentation"],"prefix":"10.1111","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4978-5254","authenticated-orcid":false,"given":"Silvan","family":"Lange","sequence":"first","affiliation":[{"name":"Institute of Medical Education LMU University Hospital, LMU Munich  Munich Germany"},{"name":"Department of Dermatology and Allergy LMU University Hospital, LMU Munich  Munich Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nils","family":"Kr\u00fcger","sequence":"additional","affiliation":[{"name":"Institute of Medical Education LMU University Hospital, LMU Munich  Munich Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maximilian","family":"Warm","sequence":"additional","affiliation":[{"name":"Institute of Medical Education LMU University Hospital, LMU Munich  Munich Germany"},{"name":"Department of Medicine III LMU University Hospital, LMU Munich  Munich Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Johanna","family":"Buechel","sequence":"additional","affiliation":[{"name":"Department for Obstetrics and Gynecology University Hospital W\u00fcrzburg, Julius\u2010Maximilians\u2010University  W\u00fcrzburg Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Orsolya","family":"Genzel\u2010Borovicz\u00e9ny","sequence":"additional","affiliation":[{"name":"Division of Neonatology Campus Innenstadt, Dr. von Hauner Children's Hospital LMU University Hospital, LMU Munich  Munich Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martin R.","family":"Fischer","sequence":"additional","affiliation":[{"name":"Institute of Medical Education LMU University Hospital, LMU Munich  Munich Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Konstantinos","family":"Dimitriadis","sequence":"additional","affiliation":[{"name":"Institute of Medical Education LMU University Hospital, LMU Munich  Munich Germany"},{"name":"Department of Neurology LMU University Hospital, LMU Munich  Munich Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2024,3,3]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/amiajnl-2012-001093"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.4300\/JGME-D-16-00235.1"},{"key":"e_1_2_12_4_1","doi-asserted-by":"publisher","DOI":"10.1002\/pbc.25725"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjoq-2020-000918"},{"key":"e_1_2_12_6_1","unstructured":"Association of American Medical Colleges Core entrustable professional activities for entering residency 2014.https:\/\/store.aamc.org\/downloadable\/download\/sample\/sample_id\/63\/"},{"key":"e_1_2_12_7_1","volume-title":"Nationaler Kompetenzbasierter Lernzielkatalog Medizin \u2010 Version 2.0","author":"Fakult\u00e4tentag M.","year":"2021"},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12909-015-0443-x"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijmedinf.2021.104526"},{"issue":"7","key":"e_1_2_12_10_1","article-title":"Evaluation of a telemedicine\u2010based training for final\u2010year medical students including simulated patient consultations, documentation, and case presentation","volume":"37","author":"Harendza S","year":"2020","journal-title":"GMS J Med Educ"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1055\/s-0042-1743580"},{"issue":"3","key":"e_1_2_12_12_1","article-title":"Online medical history taking course: opportunities and limitations in comparison to traditional bedside teaching, GMS","volume":"39","author":"Lange S","year":"2022","journal-title":"J Med Educ"},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.1097\/00001888-200211000-00023"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12909-021-02586-y"},{"key":"e_1_2_12_15_1","article-title":"Curriculum to develop documentation proficiency among medical students in an emergency medicine clerkship","volume":"17","author":"Lai J","year":"2021","journal-title":"Med Ed Portal"},{"key":"e_1_2_12_16_1","doi-asserted-by":"publisher","DOI":"10.3402\/meo.v18i0.22495"},{"key":"e_1_2_12_17_1","doi-asserted-by":"publisher","DOI":"10.1093\/jamia\/ocaa027"},{"key":"e_1_2_12_18_1","doi-asserted-by":"publisher","DOI":"10.3389\/fdgth.2022.1063141"},{"key":"e_1_2_12_19_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10689-006-9114-8"},{"key":"e_1_2_12_20_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.pec.2009.05.008"},{"key":"e_1_2_12_21_1","doi-asserted-by":"publisher","DOI":"10.5455\/aim.2016.24.202-206"},{"key":"e_1_2_12_22_1","doi-asserted-by":"publisher","DOI":"10.1097\/JPA.0000000000000205"},{"key":"e_1_2_12_23_1","doi-asserted-by":"publisher","DOI":"10.1111\/tct.12304"},{"key":"e_1_2_12_24_1","volume-title":"Anamnese und k\u00f6rperliche Untersuchung","author":"Seiderer\u2010Nack J.","year":"2018"},{"key":"e_1_2_12_25_1","doi-asserted-by":"publisher","DOI":"10.11613\/BM.2012.031"},{"key":"e_1_2_12_26_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-022-06635-5"},{"issue":"1","key":"e_1_2_12_27_1","first-page":"22","article-title":"Are students less likely to report pertinent negatives in post\u2010encounter notes?","volume":"44","author":"Walling A","year":"2012","journal-title":"Fam Med"},{"key":"e_1_2_12_28_1","doi-asserted-by":"publisher","DOI":"10.3946\/kjme.2023.259"},{"key":"e_1_2_12_29_1","volume-title":"On Intelligence","author":"Hawkins J","year":"2005"},{"key":"e_1_2_12_30_1","volume-title":"Thinking, fast and slow","author":"Kahneman D","year":"2011"},{"key":"e_1_2_12_31_1","doi-asserted-by":"publisher","DOI":"10.1097\/00001888-200610001-00012"},{"key":"e_1_2_12_32_1","doi-asserted-by":"publisher","DOI":"10.1080\/10401334.2013.857337"},{"key":"e_1_2_12_33_1","doi-asserted-by":"publisher","DOI":"10.1177\/1833358316639448"},{"key":"e_1_2_12_34_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12909-018-1403-z"},{"key":"e_1_2_12_35_1","doi-asserted-by":"publisher","DOI":"10.1111\/tct.12511"},{"issue":"5","key":"e_1_2_12_36_1","first-page":"189","article-title":"Handwriting errors: harmful, wasteful and preventable","volume":"99","author":"Bruner A","year":"2001","journal-title":"J Ky Med Assoc"},{"key":"e_1_2_12_37_1","doi-asserted-by":"publisher","DOI":"10.1136\/emermed-2015-205141"},{"key":"e_1_2_12_38_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthpol.2018.05.014"},{"key":"e_1_2_12_39_1","doi-asserted-by":"publisher","DOI":"10.1071\/AH21112"},{"key":"e_1_2_12_40_1","doi-asserted-by":"publisher","DOI":"10.1097\/ACM.0b013e3181bf9d45"},{"key":"e_1_2_12_41_1","doi-asserted-by":"publisher","DOI":"10.1080\/10401334.2012.692267"},{"key":"e_1_2_12_42_1","doi-asserted-by":"publisher","DOI":"10.1111\/jonm.12727"},{"issue":"1","key":"e_1_2_12_43_1","article-title":"Management lessons through an interactive online discussion about hospital management during the COVID\u201019 pandemic","volume":"38","author":"Leunig A","year":"2021","journal-title":"GMS J Med Educ"}],"container-title":["The Clinical Teacher"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/asmepublications.onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/tct.13749","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T15:56:51Z","timestamp":1762358211000},"score":1,"resource":{"primary":{"URL":"https:\/\/asmepublications.onlinelibrary.wiley.com\/doi\/10.1111\/tct.13749"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,3,3]]},"references-count":42,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2024,8]]}},"alternative-id":["10.1111\/tct.13749"],"URL":"https:\/\/doi.org\/10.1111\/tct.13749","archive":["Portico"],"relation":{},"ISSN":["1743-4971","1743-498X"],"issn-type":[{"value":"1743-4971","type":"print"},{"value":"1743-498X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,3,3]]},"assertion":[{"value":"2023-08-15","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-01-31","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-03-03","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e13749"}}