"Read One, Write One": Improving Medical Student Clinical Documentation on the Psychiatry Clerkship Using Example...

Area of Science:

• Medical Education
• Psychiatry
• Clinical Documentation

Background:

• Effective clinical documentation is crucial for patient care and medical education.
• Psychiatry clerkships require students to develop strong documentation skills.
• Previous methods for teaching documentation have varied in effectiveness.

Purpose of the Study:

• To evaluate the impact of a didactic educational intervention on psychiatry clerkship students' clinical documentation quality.
• To compare the documentation skills of students who received the intervention with a historical comparison group.

Main Methods:

• A 1-hour didactic session with sample writings was given to an intervention group.
• A historical comparison group did not receive the intervention.
• Student clinical notes were collected and blindly assessed using a standardized rubric.

Main Results:

• The intervention group showed significantly higher quality in their second note (N2) compared to the comparison group (77.4% vs 65.56%).
• Both groups improved from note 1 (N1) to N2, but the intervention group's improvement was significantly greater (11.7 vs 3.11 points).
• Improvements were most notable in the history of present illness, family-social history, and review of systems sections.

Conclusions:

• A brief educational intervention significantly enhances clinical documentation skills in medical students during their psychiatry clerkship.
• The findings suggest that targeted didactic training and examples are effective in improving medical student documentation.
• This intervention offers a practical approach to improving a core competency in medical training.