PDF(Pubmed)
Abstract：
Introduction Documentation within the Electronic Health Record (EHR) is an essential skill for medical students to succeed in residency and post-residency training. The increased use of medical student progress notes for billable services raises the need for the education and assessment of quality note writing. We hypothesized that structured note feedback using a note assessment tool would improve the quality of medical student inpatient progress notes. Methods We conducted a retrospective study to review the quality of student inpatient progress notes written before and after structured feedback using the Responsible Electronic Documentation (RED) checklist throughout a third-year internal medicine clerkship. The first intervention group received feedback from clerkship directors in the 2017-2018 academic year and the second intervention group received feedback from ward residents/attendings in the 2018-2019 academic year. Within each intervention group, the total note scores from pre and post-intervention were compared. Results Feedback from clerkship directors yielded a greater increase in students\' total note score from pre to post-intervention compared to ward resident/attending feedback (F(1,255) = 12.84, p < 0.001). Cohen\'s d effect size value was greater for the clerkship director feedback arm (d=0.71) compared to the ward resident/attending feedback arm (d=0.24). Post-hoc analyses using dependent sample t-tests revealed that there were significant increases in total note scores from pre to post-intervention for both the clerkship director arm (t(123) = 8.26, p < 0.001, d = 0.71) and the ward resident/attending arm (t(132) = 2.85, p = 0.005, d = 0.24). Conclusion Clerkship director feedback led to a greater increase in medical student documentation compared to ward attending/resident feedback. Nonetheless, structured feedback with a note assessment tool, whether from clerkship directors or ward attendings/residents, leads to a significant improvement in medical student documentation. Though there are various methods for providing feedback, educators can use the RED checklist to provide clear guidelines that will facilitate note-writing feedback.
摘要：
电子健康记录（EHR）中的文档是医学生在住院医师和住院医师后培训中取得成功的一项基本技能。医学生进度笔记用于收费服务的增加增加了对质量笔记写作的教育和评估的需求。我们假设使用笔记评估工具的结构化笔记反馈将提高医学生住院进度笔记的质量。方法我们进行了一项回顾性研究，以审查在整个第三年内科医师期间使用负责任的电子文档（RED）清单在结构化反馈之前和之后编写的学生住院进度记录的质量。第一个干预组在2017-2018学年收到了办事员主任的反馈，第二个干预组在2018-2019学年收到了病房居民/就诊人员的反馈。在每个干预组中，比较干预前后的总记分.结果与病房住院医师/就诊反馈相比，从干预前到干预后，书记官的反馈使学生的总笔记得分增加了更多（F（1,255）=12.84，p<0.001）。与病房住院医师/主治医师反馈臂（d=0.24）相比，职员主任反馈臂（d=0.71）的Cohen的d效应大小值更大。使用依赖样本t检验的事后分析显示，从干预前到干预后，神职人员主任组（t（123）=8.26，p<0.001，d=0.71）和病房住院医师/主治组（t（132）=2.85，p=0.005，d=0.24）的总笔记得分均显着增加。结论与病房主治医生/住院医生的反馈相比，教务主任的反馈导致医学生文件的增加更大。尽管如此，使用笔记评估工具的结构化反馈，无论是来自办事员主任还是病房主治人员/居民，导致医学生文件的显着改善。虽然有各种方法来提供反馈，教育工作者可以使用RED清单提供明确的指导方针，以促进笔记反馈。
