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"Read One, Write One": Improving Medical Student Clinical Documentation on the Psychiatry Clerkship Using Example
Gregg Robbins-Welty1, Dakota May2, Kristen Shirey3
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA. greggrobbinswelty@gmail.com.
Summary
A one-hour educational intervention significantly improved medical students' clinical documentation skills during their psychiatry clerkship, particularly in history sections. This training enhanced note quality more than standard experience alone.
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.
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