INTRODUCTION

Documenting a clinical encounter is a core skill for entering residency, but medical students often receive scant dedicated documentation training, leading to a high rate of inadequate information. Utilizing adult experiential learning theory, we created and implemented an educational resource to train medical students on how to proficiently document an emergency department (ED) patient encounter.

METHODS

One hundred and five third- and fourth-year medical students participating in an emergency medicine clerkship took part in a brief orientation day documentation curriculum that included a group didactic, a review of reference materials, a standardized patient activity, a sample patient note writing assignment with individualized feedback, and supervising faculty physician feedback on real patient notes. Students were subsequently entrusted with primary documentation responsibility for all ED patients whose care they participated in.

RESULTS

After completing this curriculum, students' self-rated comfort with writing a high-quality note increased from 4.1 to 5.9 ( < .001) and knowledge about billing and coding increased from 2.9 to 5.5 ( < .001) on a 7-point scale. Among faculty physicians, 93% found student notes to always, usually, or frequently be clinically useful, and 86% reported that student notes always, usually, or frequently contained enough information for billing and coding.

DISCUSSION

This curriculum was effective at training medical students on proficient patient care documentation in emergency medicine. The relatively short amount of synchronous learning time required could aid in implementation, and the allowance of medical student notes to count for billing purposes could facilitate student and faculty buy-in.