Assessment Tools for Patient Notes in Medical Education: A Scoping Review.

Area of Science:

• Medical Education
• Health Informatics
• Clinical Documentation

Background:

• Physician proficiency in clinical documentation is crucial for patient safety, healthcare quality, and cost-effectiveness.
• Deficiencies in medical note writing are frequently identified, posing significant challenges.

Purpose of the Study:

• To create a compendium of tools for assessing clinical encounter documentation.
• To support educators in practical implementation and future research on improving physician documentation.

Main Methods:

• A comprehensive scoping review was conducted using the Arksey and O'Malley framework.
• Searched multiple databases (PubMed, Embase, Web of Science, etc.) for articles on documentation and assessment tools.
• Extracted data on tool properties, usage, learner performance, and stakeholder satisfaction.

Main Results:

• 32 studies with unique assessment tools were included, with a surge in publications since 2018.
• Most studies focused on creating new tools, with note writers often showing incomplete documentation (average score 60.3%).
• No tools reported on equity, fairness, or patient readability; about half were open access.

Conclusions:

• Diverse tools exist to assess patient notes and identify documentation deficiencies.
• This compendium can aid educators and researchers in enhancing patient care documentation.