Tracking the evolution of medical students' clinical documentation skills: a pilot study leveraging a simulated...

Clinical documentation skills (CDS) are crucial for effective medical practice. Accurate and structured documentation ensures continuity of care, supports clinical decision-making, and serves as a legal record of healthcare delivery. This study aimed to evaluate the progression of CDS of the medical students across core clinical rotations using a simulation-based modified Standardized Long Case Examination of Clinical Competence (m-SLCECC).

We performed a longitudinal analysis of the progression of 3^rd year medical students' CDS on the history of present illness (HPI), and assessment and plan (A&P) using simulation-based assessment in five clinical disciplines over seven months. During the simulation-based clinical assessment of m-SLCECC, students completed post-encounter documentation tasks. Data were collected via the LearningSpace™ system and analyzed using pooled panel data estimation. Three separate regression models evaluated improvements in HPI, plan, and assessment documentation scores over time, adjusting for clerkship- and case-specific variables.

The medical students' CDS scores improved across all domains over the study period. HPI scores increased by 0.17 points per month (p = 0.01), assessment by 0.15 points (p = 0.02), and planning scores by 0.22 points (p < 0.001). Assessment scores showed the greatest variability (R² = 0.42) compared to HPI (R² = 0.20) and plan (R² = 0.27). However, clerkship-specific variations and differences in case content influenced the degree of improvement.

Simulation-based longitudinal assessment effectively captured progressive improvements in students' CDS. Variations in performance highlight the influence of rotation-specific factors and underscore the need for targeted feedback strategies to optimize CDS development. Panel data analysis in this study proved a robust methodological tool for tracking skill evolution over time.