Documenting Performance and Feedback in Medical Education: An Essential Skill

Documentation of performance provides feedback to medical trainees on their progress and is required by Programs as a record for monitoring whether trainees are achieving expectations against accepted standards. Despite the importance of performance documentation and the focus on improving feedback delivery in medical education, there has been little written in the literature on documentation best practices. Documentation is an essential skill that cannot be learned solely by observation, as most is confidential. However, teaching documentation of learner performance is rarely discussed. This article describes the authors' experience in teaching the skill of effective documentation of trainee performance for the purpose of providing feedback, monitoring progress, and recording evaluations.