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A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era.


ABSTRACT:

Introduction

New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both benefits and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for first-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note.

Methods

One hundred seventy-three first-year medical and dental students participated in this curriculum. They completed an asynchronous presession module first, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices.

Results

On postworkshop surveys, learners reported increased preparedness in their ability to document in a patient-centered manner (presession M = 2.2, midyear M = 3.9, p < .001), as rated on a 5-point Likert scale (1 = not prepared at all, 5 = very prepared), and also found this topic valuable to learn early in their training.

Discussion

This curriculum utilizes a multipart approach to prepare learners to employ clinical notes to communicate with patients and providers, with special attention to how patients and their care partners receive a note. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.

SUBMITTER: Eng K 

PROVIDER: S-EPMC10963659 | biostudies-literature | 2024

REPOSITORIES: biostudies-literature

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A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era.

Eng Kathleen K   Johnston Katherine K   Cerda Ivo I   Kadakia Kushal K   Mosier-Mills Alison A   Vanka Anita A  

MedEdPORTAL : the journal of teaching and learning resources 20240326


<h4>Introduction</h4>New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both benefits and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for first-year medical students within their foundational clinical skill  ...[more]

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