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Student Competency in Outpatient Documentation: Insights From the 2025 CERA Clerkship Directors Study
William Dabbs1, Tomoko Sairenji2, Samira Farah2
1College of Medicine, The University of Tennessee Health Science Center, Knoxville, TN.
Family Medicine
|August 3, 2026
Summary
Family medicine clerkships show significant variability in teaching and assessing clinical documentation skills. Many programs lack structured methods, highlighting a need for standardized approaches to ensure student competency before residency.
Area of Science:
- Medical Education
- Clinical Skills Assessment
- Health Informatics
Background:
- Clinical documentation competency is a crucial entrustable professional activity for graduating medical students.
- National organizations have set expectations for documentation training, yet practical implementation and assessment guidance are limited.
- Current educational practices in outpatient documentation are not well understood.
Purpose of the Study:
- To characterize the educational practices for teaching and assessing outpatient clinical documentation competency in family medicine clerkships.
- To identify the extent of formal instruction, assessment methods, and evaluation processes used.
Main Methods:
- Cross-sectional analysis of five documentation-related items from the 2025 Council of Academic Family Medicine Educational Research Alliance clerkship directors survey.
- Survey distributed to 174 US and Canadian family medicine clerkship directors.
- Descriptive statistics used to summarize survey responses.
Main Results:
- A 57.4% response rate was achieved (100/174 directors).
- Most directors (78.7%) consider assessing documentation competency important or very important.
- Significant variation exists in teaching methods (33.3% lack formal instruction) and assessment (56.4% informal, 8.5% no formal process).
- Formal evaluation of accuracy and integrity is lacking in 37.6% of programs.
Conclusions:
- Teaching and assessment of outpatient documentation competency in family medicine clerkships are highly variable.
- Many programs lack structured educational approaches and formal assessment processes.
- Standardized guidelines and curricular integration are needed to ensure consistent competency achievement before residency.
Related Concept Videos
01:23Methods of Documentation V: CBE
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In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
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01:29Documentation in Long-Term and Home Healthcare Setting
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Long-Term Care Facilities
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01:21Methods of Documentation III: PIE
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01:18Methods of Documentation I: Source-Oriented Records
Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
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Key Attributes include the following:
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01:30Methods of Documentation VII: EMR
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
01:15Methods of Documentation VI: Case Management Model
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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