Wilesmith Sarah, Mandrusiak Allison, Lang Ray, Martin Romany, Lu Andric, Forbes Roma
School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
School of Health Sciences, University of Tasmania, Launceston, Australia.
Clin Teach. 2025 Oct;22(5):e70157. doi: 10.1111/tct.70157.
Clinical documentation is necessary for effective and safe healthcare practice. This paper systematically reviewed educational interventions aimed at developing entry-level health professional students' clinical documentation skills.
A systematic search of electronic databases (PubMed, CINAHL, Embase and Cochrane) from January 2000 to May 2023 was performed, with additional forward and backward citation searching. Inclusion was limited to original manuscripts published in English from January 2000, reporting an experimental or quasi-experimental design and using objective performance-based measures. Quality appraisal was conducted using the Medical Education Research Study Quality Instrument (MERSQI), with narrative synthesis of results due to the heterogeneity of outcome measures.
Of 5313 records identified, 29 studies were eligible for inclusion. The health professions represented were medicine, dentistry, nursing, pharmacy, psychology and veterinary science. Teaching methodologies included the following: didactic instruction; provision of templates, guidelines and/or examples; instructor-led group discussion; individual or group instructor feedback; near-peer or peer feedback; self-evaluation; writing practice activities; worked examples; and response-to-stimulus writing activities (written, video or live standardised patient cases). Research quality was low in MERSQI domains of 'study design' and 'validity of evaluation instruments'.
Several training methods appear valuable in developing student skills in clinical documentation; however, high-quality evaluation of documentation training interventions is lacking. Future research is recommended to compare existing methods of documentation training and to evaluate training in underexplored healthcare disciplines.
临床文档记录对于有效且安全的医疗实践至关重要。本文系统回顾了旨在培养初级卫生专业学生临床文档记录技能的教育干预措施。
对2000年1月至2023年5月的电子数据库（PubMed、CINAHL、Embase和Cochrane）进行了系统检索，并进行了额外的向前和向后引文检索。纳入范围限于2000年1月以来发表的英文原创手稿，报告实验性或准实验性设计，并使用基于客观表现的测量方法。使用医学教育研究质量工具（MERSQI）进行质量评估，由于结果测量的异质性，对结果进行叙述性综合。
在识别出的5313条记录中，29项研究符合纳入标准。所涉及的卫生专业包括医学、牙科、护理、药学、心理学和兽医学。教学方法包括：讲授式教学；提供模板、指南和/或示例；教师主导的小组讨论；个人或小组教师反馈；近同伴或同伴反馈；自我评价；写作练习活动；实例；以及对刺激的写作活动（书面、视频或现场标准化患者案例）。在“研究设计”和“评估工具的有效性”的MERSQI领域中，研究质量较低。
几种培训方法在培养学生的临床文档记录技能方面似乎很有价值；然而，缺乏对文档记录培训干预措施的高质量评估。建议未来的研究比较现有的文档记录培训方法，并评估在未充分探索的医疗保健学科中的培训。
