Stakeholder-Informed Needs Assessment for Open Notes Curriculum in Inpatient Pediatrics

Area of Science:

• Medical Education
• Health Informatics
• Patient-Centered Care

Background:

• The 21st Century Cures Act requires real-time patient access to clinical notes, impacting medical education.
• Inpatient pediatrics presents unique challenges for Open Notes, including confidentiality and sensitive topics.
• Medical students currently receive limited formal training in creating patient-readable notes (Open Notes).

Purpose of the Study:

• To conduct a stakeholder-informed needs assessment for developing curricula on medical student documentation in inpatient pediatrics.
• To address the challenges posed by the Open Notes era in undergraduate medical education.

Main Methods:

• A multi-site qualitative study involving focus groups with diverse stakeholders.
• Participants included medical students, residents, fellows, and faculty across four academic institutions.
• Inductive thematic analysis was used to analyze focus group transcripts.

Main Results:

• Four core content domains for Open Notes curricula were identified: audience adaptation, patient-centered language, documenting uncertainty, and managing confidentiality/proxy access.
• Stakeholders advocated for a longitudinal curriculum with early introduction, practice, feedback, and EHR tool integration.
• A need for structured training and institutional support was emphasized.

Conclusions:

• Medical students require specific training to effectively document in the Open Notes environment.
• This study offers a framework for developing undergraduate medical education curricula for pediatric inpatient documentation.