Abstract
Purpose
To determine whether a formal note-writing session and note template for medical students
(MS) during the Core Clerkship in Pediatrics (CCP) increases note quality, shortens
note length, and decreases time of documentation.
Methods
In this single site, prospective study, MS participating in an 8-week CCP received
a didactic session on note-writing in the electronic health record (EHR) and utilized
EHR template developed for the study. We assessed note quality [measured by Physician
Documentation Quality Instrument-9 (PDQI-9)], note length and note documentation time
in this group compared to MS notes on the CCP in the prior academic year. We used
descriptive statistics and Kruskal-Wallis tests for analysis.
Results
We analyzed 121 notes written by 40 students in the control group and 92 notes writing
by 41 students in the intervention group. Notes from the intervention group were more
“up to date,” “accurate,” “organized,” and “comprehensible” compared to the control
group (p=0.02, p=0.04, p=0.01, and p=0.02, respectively). Intervention group notes
received higher cumulative PDQI-9 scores compared to the control group (median score
38 (IQR 34-42) vs 36 (IQR 32-40) out of 45 total, p=0.04). Intervention group notes
were approximately 35% shorter than the control group notes (median 68.5 lines vs
105 lines, p <0.0001) and were signed earlier than control group notes (median file
time 316 minutes vs 352 minutes, p=0.02).
Conclusions
The intervention successfully decreased note length, improved note quality based on
standardized metrics, and reduced time to completion of note documentation.
WHAT’S NEW
An innovative note writing curriculum and accompanying standardized note template
improved the outcomes of medical student progress notes in multiple domains, including
timeliness, accuracy, organization, and overall quality.” The intervention also significantly
decreased note length and time to note completion.
Keywords
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References
- for Core EPAs for Entering Residency Pilot Program.in: Obeso V. Brown D. Aiyer M. Barron B. Bull J. Carter T. Emery M. Gillespie C. Hormann M. Hyderi A. Lupi C. Schwartz M. Uthman M. Vasilevskis E.E. Yingling S. Phillipi C. Toolkits for the 13 Core Entrustable Professional Activities for Entering Residency. Association of American Medical Colleges, Washington, DC2017
Office of the National Coordinator for Health Information Technology . 'Hospitals Participating in the CMS EHR Incentive Programs,' Health IT Quick-Stat #45. dashboard.healthit.gov/quickstats/pages/FIG-Hospitals-EHR-Incentive-Programs.php. August 2017.
- A Prescription for Note Bloat: An Effective Progress Note Template.J. Hosp. Med. 2018; 6: 378-382https://doi.org/10.12788/jhm.2898
- A piece of my mind. Copy-and-paste.JAMA. 2006; 295: 2335-2336
- A piece of my mind. John Lennon’s elbow.JAMA. 2012; 308: 463-464
- Characterizing the source of text in electronic health record progress notes.JAMA internal medicine. 2017; 177: 1212-1213
Center for Medicare & Medicaid Services ( 2018 ). E/M Service Documentation Provided By Students (Manual Update). Retrieved from 〈https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM10412.pdf〉
- Thomas P.A. Kern D.E. Hughes M.T. Tackett S.A. Chen B.Y. Curriculum development for medical education: a six-step approach. JHU press, 2022
- Adult Learning Theories in Context: A Quick Guide for Healthcare Professional Educators.Journal of Medical Education and Curricular Development. 2019; 6https://doi.org/10.1177/2382120519840332
- Assessing electronic note quality using the physician documentation quality instrument (PDQI-9).Applied clinical informatics. 2012; 3: 164
- Electronic Health Record Effects on Work-Life Balance and Burnout Within the I3 Population Collaborative.J Grad Med Educ. 2017 Aug; 9 (PMID: 28824762; PMCID: PMC5559244.): 479-484https://doi.org/10.4300/JGME-D-16-00123.1
AMA: New 2023 CPT code set includes burden-reducing revisions. (2022, September 9). Retrieved February 2, 2023, from 〈https://www.ama-assn.org/press-center/press-releases/ama-new-2023-cpt-code-set-includes-burden-reducing-revisions〉.
AMA: New 2023 CPT code set includes burden-reducing revisions. (2022, September 9). Retrieved February 2, 2023, from 〈https://www.ama-assn.org/press-center/press-releases/ama-new-2023-cpt-code-set-includes-burden-reducing-revisions〉.
- Documentation as composing: how medical students and residents use writing to think and learn.Adv in Health Sci Educ. 2022; https://doi.org/10.1007/s10459-022-10167-x
Article info
Publication history
Accepted:
February 27,
2023
Received:
May 19,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
All rights reserved.
