Clinical Note Assessment Tool Boosts Student EHR Documentation Quality

Clerkship director feedback was more effective than ward resident feedback in improving student EHR documentation quality through the use of a clinical note assessment tool, according to a study published by Cureus.

Researchers reviewed the quality of student inpatient progress notes before and after structured feedback using the Responsible Electronic Documentation (RED) checklist during a third-year internal medicine clerkship.

The first intervention group received feedback from clerkship directors in the 2017-2018 academic year. The second group received input from ward residents/attendings in the 2018-2019 academic year.

The study found that feedback from clerkship directors yielded a more significant increase in students’ total note scores from pre- to post-intervention.

Additionally, the research revealed that students’ pre-intervention total note scores were lower, on average, when graded by clerkship directors compared to ward residents/attendings.

The study authors proposed four possible reasons for the different findings between the two groups.

First, they noted that clerkship directors have much more experience giving feedback to students than residents and most attendings.

“Clerkship directors are likely more effective teachers with more experience giving feedback compared to residents who lack experience and instruction on giving effective feedback,” the study authors wrote.

Second, the researchers pointed to potential differences related to knowledge of the RED Checklist between ward residents and clerkship directors.

“More experience with the assessment tool likely contributed to the larger increase of total note scores from pre- to post-intervention and the larger effect size in the clerkship director arm,” they wrote. “Though the RED checklist is able to be utilized by individuals using it for the first time, those who are unfamiliar with the RED checklist will need to consult a detailed key to grade progress notes.”

Next, the researchers suggested that the differences in student clinical documentation improvement between the intervention groups could be associated with clerkship directors having more time for formal feedback.

“Residents are busy and resident teams are often capped at full patient loads,” the researchers wrote. “They may be preoccupied with more pressing clinical duties that supersede teaching,”

The study authors said they suspect residents could have rushed through grading and feedback compared to clerkship directors who had a dedicated period to give detailed student feedback.

Lastly, the researchers pointed to social aspects that may have led to differences in how clerkship directors and ward residents scored students’ clinical documentation quality.

“We suspect a culture of politeness is present to avoid damaging a student’s self-esteem with constructive criticism,” they wrote.

“Face-to-face evaluations of junior medical students resulted in grade inflation in one study,” they noted “Though these factors were likely present in both interventions, we hypothesize that there was a greater influence in the second intervention consisting of mostly resident evaluators due to the ‘social desirability bias.’”

Since residents spend more time with medical students throughout a clerkship, they may be more likely to give higher scores to build and maintain strong relationships with students, the authors suggested.

They noted that although clerkship director feedback was more effective than ward resident/attending feedback, post-hoc analyses showed that the quality of medical student notes improved significantly regardless of the source of feedback.