"Read One, Write One": Improving Medical Student Clinical Documentation on the Psychiatry Clerkship Using Example Notes

Abstract

Objective: The authors examined the effectiveness of an educational intervention aimed at improving psychiatry clerkship student clinical documentation skills.

Method: A 1-h didactic and "gold standard" sample writings of clinical documentation were provided to psychiatry clerkship medical students rotating on an academic consultation-liaison (CL) service between July 2022 and August 2023 (intervention group). A historical comparison group of medical students, rotating between January and June 2022, did not receive the intervention. Two examples of student documentation were collected, including note 1 (N1) during week 1 and note 2 (N2) during week 2. Note quality was assessed blindly using a standardized 100-point grading rubric.

Results: Thirty psychiatry clerkship students provided 60 examples of clinical documentation. There were no differences between N1 scores between groups. N2 mean scores were significantly greater in the intervention group over the comparison (77.4% vs 65.56%, p = 0.02). While all groups demonstrated improvement between N1 and N2, intervention groups improved significantly more than the comparison group (3.11 vs 11.7, p < 0.01). Improvements were observed most in the history of present illness, family-social history, and review of systems sub-sections. Time of year, a proxy for student experience, did not impact note scores.

Conclusions: Providing medical students with a didactic and examples of clinical documentation improved medical student documentation on the psychiatry clerkship.

Keywords: Clinical documentation; Clinical informatics; Electronic health record; Medical student education; Psychiatry clerkship.