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Confidence and Efficiency Improvements in Medical Student Notes After Implementation of a Standardized Note Template
Michael Houghan1, Jennifer Passini2, Fauzia Hollnagel2
1Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, houghan@wisc.edu.
Summary
Standardized clinical note templates improved medical students' confidence and efficiency in documentation. While progress notes became shorter, admission notes increased in length, indicating a shift in documentation patterns.
Area of Science:
- Medical Education
- Clinical Documentation
- Health Informatics
Background:
- Clinical note writing is a crucial yet challenging skill for medical students.
- Traditional methods of teaching clinical note writing often fall short due to its stylized nature.
Purpose of the Study:
- To evaluate the impact of standardized note templates with embedded help text on medical students' note-writing skills.
- To assess changes in students' self-perceived confidence, efficiency, and note characteristics.
Main Methods:
- Development of standardized inpatient admission and daily progress note templates with integrated guidance.
- Utilized pre- and post-intervention surveys to measure student confidence and efficiency.
- Analyzed note length as an objective measure of documentation.
Main Results:
- Student confidence in writing assessment and plan sections significantly increased post-intervention (17.4% to 83.3%).
- Perceived efficiency in writing admission and progress notes improved substantially.
- Average progress note length decreased by 13.8%, while average admission note length increased by 19.3%.
Conclusions:
- Standardized note templates are well-received by medical students, enhancing confidence and perceived efficiency.
- Template implementation led to a reduction in progress note length but an increase in admission note length.
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