Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship

Introduction Documenting a clinical encounter is a core skill for entering residency, but medical students often receive scant dedicated documentation training, leading to a high rate of inadequate information. Utilizing adult experiential learning theory, we created and implemented an educational r...

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Autores principales:	Jason Lai, David Tillman
Formato:	article
Lenguaje:	EN
Publicado:	Association of American Medical Colleges 2021
Materias:	Documentation Emergency Medicine Clerkship Patient Note Standardized Patient Systems-Based Practice Medicine (General) R5-920 Education L
Acceso en línea:	https://doaj.org/article/38410090d4d44054b38af99d11a593e4
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spelling	oai:doaj.org-article:38410090d4d44054b38af99d11a593e42021-11-15T04:00:08ZCurriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship10.15766/mep_2374-8265.111942374-8265https://doaj.org/article/38410090d4d44054b38af99d11a593e42021-11-01T00:00:00Zhttp://www.mededportal.org/doi/10.15766/mep_2374-8265.11194https://doaj.org/toc/2374-8265Introduction Documenting a clinical encounter is a core skill for entering residency, but medical students often receive scant dedicated documentation training, leading to a high rate of inadequate information. Utilizing adult experiential learning theory, we created and implemented an educational resource to train medical students on how to proficiently document an emergency department (ED) patient encounter. Methods One hundred and five third- and fourth-year medical students participating in an emergency medicine clerkship took part in a brief orientation day documentation curriculum that included a group didactic, a review of reference materials, a standardized patient activity, a sample patient note writing assignment with individualized feedback, and supervising faculty physician feedback on real patient notes. Students were subsequently entrusted with primary documentation responsibility for all ED patients whose care they participated in. Results After completing this curriculum, students’ self-rated comfort with writing a high-quality note increased from 4.1 to 5.9 (p < .001) and knowledge about billing and coding increased from 2.9 to 5.5 (p < .001) on a 7-point scale. Among faculty physicians, 93% found student notes to always, usually, or frequently be clinically useful, and 86% reported that student notes always, usually, or frequently contained enough information for billing and coding. Discussion This curriculum was effective at training medical students on proficient patient care documentation in emergency medicine. The relatively short amount of synchronous learning time required could aid in implementation, and the allowance of medical student notes to count for billing purposes could facilitate student and faculty buy-in.Jason LaiDavid TillmanAssociation of American Medical CollegesarticleDocumentationEmergency MedicineClerkshipPatient NoteStandardized PatientSystems-Based PracticeMedicine (General)R5-920EducationLENMedEdPORTAL, Vol 17 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	Documentation Emergency Medicine Clerkship Patient Note Standardized Patient Systems-Based Practice Medicine (General) R5-920 Education L
spellingShingle	Documentation Emergency Medicine Clerkship Patient Note Standardized Patient Systems-Based Practice Medicine (General) R5-920 Education L Jason Lai David Tillman Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship
description	Introduction Documenting a clinical encounter is a core skill for entering residency, but medical students often receive scant dedicated documentation training, leading to a high rate of inadequate information. Utilizing adult experiential learning theory, we created and implemented an educational resource to train medical students on how to proficiently document an emergency department (ED) patient encounter. Methods One hundred and five third- and fourth-year medical students participating in an emergency medicine clerkship took part in a brief orientation day documentation curriculum that included a group didactic, a review of reference materials, a standardized patient activity, a sample patient note writing assignment with individualized feedback, and supervising faculty physician feedback on real patient notes. Students were subsequently entrusted with primary documentation responsibility for all ED patients whose care they participated in. Results After completing this curriculum, students’ self-rated comfort with writing a high-quality note increased from 4.1 to 5.9 (p < .001) and knowledge about billing and coding increased from 2.9 to 5.5 (p < .001) on a 7-point scale. Among faculty physicians, 93% found student notes to always, usually, or frequently be clinically useful, and 86% reported that student notes always, usually, or frequently contained enough information for billing and coding. Discussion This curriculum was effective at training medical students on proficient patient care documentation in emergency medicine. The relatively short amount of synchronous learning time required could aid in implementation, and the allowance of medical student notes to count for billing purposes could facilitate student and faculty buy-in.
format	article
author	Jason Lai David Tillman
author_facet	Jason Lai David Tillman
author_sort	Jason Lai
title	Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship
title_short	Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship
title_full	Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship
title_fullStr	Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship
title_full_unstemmed	Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship
title_sort	curriculum to develop documentation proficiency among medical students in an emergency medicine clerkship
publisher	Association of American Medical Colleges
publishDate	2021
url	https://doaj.org/article/38410090d4d44054b38af99d11a593e4
work_keys_str_mv	AT jasonlai curriculumtodevelopdocumentationproficiencyamongmedicalstudentsinanemergencymedicineclerkship AT davidtillman curriculumtodevelopdocumentationproficiencyamongmedicalstudentsinanemergencymedicineclerkship
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Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship

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