A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era

A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era. Eng, K., Johnston, K., Cerda, I., Kadakia, K., Mosier-Mills, A., & Vanka, A. MedEdPORTAL, March, 2024.

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Introduction: New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both beneﬁts and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for ﬁrst-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. Methods: One hundred seventy-three ﬁrst-year medical and dental students participated in this curriculum. They completed an asynchronous presession module ﬁrst, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices. Results: On postworkshop surveys, learners reported increased preparedness in their ability to document in a patient-centered manner (presession M = 2.2, midyear M = 3.9, p \textless .001), as rated on a 5-point Likert scale (1 = not prepared at all, 5 = very prepared), and also found this topic valuable to learn early in their training. Discussion: This curriculum utilizes a multipart approach to prepare learners to employ clinical notes to communicate with patients and providers, with special attention to how patients and their care partners receive a note. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.

@article{eng_patient-centered_2024,
	title = {A {Patient}-{Centered} {Documentation} {Skills} {Curriculum} for {Preclerkship} {Medical} {Students} in an {Open} {Notes} {Era}},
	issn = {2374-8265},
	url = {http://www.mededportal.org/doi/10.15766/mep_2374-8265.11392},
	doi = {10.15766/mep_2374-8265.11392},
	abstract = {Introduction: New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both beneﬁts and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for ﬁrst-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. Methods: One hundred seventy-three ﬁrst-year medical and dental students participated in this curriculum. They completed an asynchronous presession module ﬁrst, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices. Results: On postworkshop surveys, learners reported increased preparedness in their ability to document in a patient-centered manner (presession M = 2.2, midyear M = 3.9, p {\textless} .001), as rated on a 5-point Likert scale (1 = not prepared at all, 5 = very prepared), and also found this topic valuable to learn early in their training. Discussion: This curriculum utilizes a multipart approach to prepare learners to employ clinical notes to communicate with patients and providers, with special attention to how patients and their care partners receive a note. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.},
	language = {en},
	urldate = {2026-07-15},
	journal = {MedEdPORTAL},
	author = {Eng, Kathleen and Johnston, Katherine and Cerda, Ivo and Kadakia, Kushal and Mosier-Mills, Alison and Vanka, Anita},
	month = mar,
	year = {2024},
	pages = {11392},
}

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We developed this session for ﬁrst-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. Methods: One hundred seventy-three ﬁrst-year medical and dental students participated in this curriculum. They completed an asynchronous presession module ﬁrst, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices. 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