Improving Medical Student Inpatient Documentation Through Feedback Using a Note Assessment Tool.

Area of Science:

• Medical Education
• Health Informatics

Background:

• Documentation in Electronic Health Records (EHR) is crucial for medical students.
• High-quality note writing is essential for billable services and clinical training.
• Structured feedback tools are needed to assess and improve medical student documentation.

Purpose of the Study:

• To evaluate the impact of structured feedback using the Responsible Electronic Documentation (RED) checklist on the quality of medical student inpatient progress notes.
• To compare the effectiveness of feedback from clerkship directors versus ward residents/attendings.

Main Methods:

• A retrospective study analyzed medical student progress notes before and after structured feedback.
• The Responsible Electronic Documentation (RED) checklist was used for assessment.
• Two intervention groups received feedback from either clerkship directors or ward residents/attendings.

Main Results:

• Both feedback groups showed significant improvement in total note scores post-intervention.
• Clerkship director feedback resulted in a greater increase in note scores (Cohen's d = 0.71) compared to resident/attending feedback (Cohen's d = 0.24).
• Statistical analysis confirmed significant improvements for both feedback arms (p < 0.001 and p = 0.005).

Conclusions:

• Structured feedback, particularly from clerkship directors, enhances medical student documentation quality.
• The RED checklist provides a valuable framework for delivering effective note-writing feedback.
• Regardless of the feedback provider, structured assessment tools improve medical student EHR documentation.