Improving trainee clinical documentation through a novel curriculum in internal medicine

Area of Science:

• Medical Education
• Clinical Documentation Improvement
• Healthcare Quality

Background:

• Clinical documentation is crucial in medical practice.
• Trainees often lack formal training in documentation and its assessment.
• Effective methods for improving clinical documentation are not well-established.

Purpose of the Study:

• To evaluate the impact of a new documentation curriculum on the quality of intern admission notes.
• To determine if formal training and feedback improve medical documentation.

Main Methods:

• The study assessed admission notes from University of Cincinnati interns before and after curriculum implementation.
• The Admission Note Assessment Tool (ANAT), comprising 16 checklist and 2 global items, was used for evaluation.
• Data were collected at two time points per year to differentiate intervention effects from time-related improvements.

Main Results:

• Six ANAT items demonstrated statistically significant improvements.
• The 'review of systems' item improved solely due to the intervention (OR: 3.61, p < .001).
• Improvements in 'assessment and plan' and 'global assessment' were time-dependent, while 'physical exam' and 'diagnostic data' improved with both intervention and time.

Conclusions:

• A formal documentation curriculum incorporating educational sessions and routine feedback can enhance specific aspects of clinical documentation.
• Some elements of medical documentation naturally improve over time.
• This study highlights the value of structured training in improving the quality of trainee clinical notes.