Improving Student Documentation in the Emergency Department
Abstract
Learning Objectives: Demonstrate a curriculum designed to teach medical students how to successfully write the medical decision making portion of the emergency medicine note.
Introduction: Documentation is an essential component of patient care in the emergency department (ED). Although students are taught the general rules of note-writing prior to clerkships, the emergency medicine (EM) note differs from most rotations. There is a need to teach the specifics of documentation of the EM note to medical students. The Emergency Medicine Residents’ Association (EMRA) Education Committee created a curriculum to teach formal documentation to medical students.
Educational Objective: Create a curriculum designed to teach medical students how to successfully write the medical decision making (MDM) portion of the EM note.
Curricular Design: Our curriculum design assumes that all senior medical students were taught the basics of writing a history and physical. Therefore, we primarily focused on teaching the MDM portion of the EM note. Following IRB approval and consent from the 55 students in our study, each student filled out a survey about their previous experience with documentation in the ED (Image 1). Next, students watched a video of a complete simulated patient encounter in order to assess their baseline ability to document a formal MDM that included the ED course and disposition. These notes were then graded on a rubric (Image 2) by a resident physician at each site who was a member of the curriculum development team to ensure standardization. Students were then given access to the EMRA documentation template and video. After the educational intervention, students documented a new MDM based on a different video encounter and were graded again.
Impact/Effectiveness: We found that a documentation curriculum significantly improved students’ MDM documentation. Repeated measures ANOVA revealed a strong effect on MDM Documentation scores [F(1, 38) = 72.547, p < .001, ηp2 = .656], demonstrating that MDM documentation statistically improved after the training curriculum and that implementation improves student documentation in the ED.