Confidence and Efficiency Improvements in Medical Student Notes After Implementation of a Standardized Note Template

Writing a clinical note is an essential skill that students learn during clinical rotations, but the skill is highly stylized and can be difficult to teach.

We developed standardized note templates with embedded help text for students to use when writing inpatient admission and daily progress notes. The templates were designed to provide guidance on key features of a note and to build students' self-perceived confidence and efficiency in note-writing. Pre- and post-intervention surveys and note length measurements were used to evaluate the intervention.

Students' self-rated confidence in writing an assessment and plan increased from 17.4% before the intervention to 83.3% after. Their self-rated ability to write admission and progress notes described as "efficient or very efficient" increased from 23.9% to 58.3% and 67.3% to 91.7%, respectively. A substantial majority of students used the templates and found them very or somewhat helpful in organizing an assessment and plan and for distinguishing important from unnecessary information. During this intervention, average progress note length decreased by 13.8% (95% CI, 5792.8 - 4882.65, P < .001), while average admission note length increased by 19.3%.

Implementing a standardized note template was well received by medical students and improved their confidence and perceived efficiency. Template use reduced progress note length but increased admission note length.