Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Jan;17(1):28-35.
doi: 10.1002/jhm.27410.

Improving trainee clinical documentation through a novel curriculum in internal medicine

Danielle E Weber  1   2 , Justin D Held  1 , Roman A Jandarov  1 , Matthew Kelleher  1   2 , Benjamin Kinnear  1   2 , Dana R Sall  3 , Jennifer K O'Toole  1   2
Affiliations

Improving trainee clinical documentation through a novel curriculum in internal medicine

Danielle E Weber et al. J Hosp Med. 2022 Jan.

Abstract

Background: Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown.

Objective: The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality.

Designs: Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention.

Settings and participants: Admission notes written by University of Cincinnati interns were assessed.

Interventions: The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback.

Main outcomes and measures: Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT).

Results: Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (β = .08, p = .03 and β = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time.

Conclusion: Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.

PubMed Disclaimer

Comment in

References

REFERENCES

    1. Burke HB, Sessums LL, Hoang A, et al. Electronic health records improve clinical note quality. J Am Med Inform Assoc. 2014;22(1):199‐205.
    1. Burke HB, Hoang A, Becher D, et al. QNOTE: an instrument for measuring the quality of EHR clinical notes. J Am Med Inform Assoc. 2014;21(5):910‐916.
    1. Kuhn T, Basch P, Barr M, Yackel T. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162(4):301‐303.
    1. Stetson PD, Morrison FP, Bakken S, Johnson SB, eNote Research Team. Preliminary development of the physician documentation quality instrument. J Am Med Inform Assoc. 2008;15(4):534‐541.
    1. Stetson PD, Bakken S, Wrenn JO, Siegler EL. Assessing electronic note quality using the physician documentation quality instrument (PDQI‐9). Appl Clin Inform. 2012;3(2):164‐174.

LinkOut - more resources