Cut & Paste, Note Bloat, and Patient Readers: Teaching the Teachers Patient-Centered Documentation Skills
Since the implementation of the 21 Century Cures Act in April 2021, new federal rules mandate that all patients (with several permitted exceptions) are offered rapid, online access to their clinical records, including the notes written by clinicians ('open notes'). Patients and their family members are now able to read daily progress notes in the inpatient and outpatient settings.
Resident physicians and faculty are often the primary teachers of documentation skills for students on medicine clerkships and sub-internships. It is important that students understand the principles of effective patient-centered documentation and that their faculty and resident teachers are well-equipped to teach, role-model these skills, and provide specific feedback to students on their clinical notes.
The focus of this workshop seeks to build a framework for teaching resident trainees and faculty best practices for providing feedback on student documentation skills, with a clear understanding of effective patient-centered documentation. The workshop will include a review of background literature, common patient concerns, and methods for providing feedback to students. Workshop leaders will share their approach for teaching residents and faculty documentation skills, including a checklist of best practices for writing patient-centered clinical notes, and frameworks for feedback. Participants will have time in small groups to brainstorm ways in which they can implement documentation feedback skills teaching at their institutions. Finally, we will have a large group discussion to share best practices and ideas.
Resident physicians and faculty are often the primary teachers of documentation skills for students on medicine clerkships and sub-internships. It is important that students understand the principles of effective patient-centered documentation and that their faculty and resident teachers are well-equipped to teach, role-model these skills, and provide specific feedback to students on their clinical notes.
The focus of this workshop seeks to build a framework for teaching resident trainees and faculty best practices for providing feedback on student documentation skills, with a clear understanding of effective patient-centered documentation. The workshop will include a review of background literature, common patient concerns, and methods for providing feedback to students. Workshop leaders will share their approach for teaching residents and faculty documentation skills, including a checklist of best practices for writing patient-centered clinical notes, and frameworks for feedback. Participants will have time in small groups to brainstorm ways in which they can implement documentation feedback skills teaching at their institutions. Finally, we will have a large group discussion to share best practices and ideas.