Korean J Med Educ.  2024 Sep;36(3):335-340. 10.3946/kjme.2024.307.

Enhancing medical students’ documentation skills: the impact of an assessment and feedback program

• Ji YA
• Park JJ
• Seo Jh

• KMID: 2558860
• DOI: http://doi.org/10.3946/kjme.2024.307

Abstract

Purpose
We not only developed a clinical practice program for the assessment and feedback vis-à-vis medical students’ medical records but also evaluated the effectiveness of this program via a self-assessment of medical students’ competence in writing medical records pre- and post-program.
Methods
In 2022, 74 third-year medical students were divided into four groups and participated in a 2-week program. The students’ medical records were graded on a scale ranging from 1 to 3 daily, and the mean scores for 2 weeks were compared. Pre- and post-program, the students’ self-assessment survey was conducted.
Results
The mean scores increased from 1.30 in the first week to 2.14 in the second week. The mean score of self-assessment showed significant improvements, increasing from 2.43 to 4.00 for medical record, 2.64 to 4.08 for write present illness, 2.08 to 3.89 for initial orders, 2.35 to 4.34 for signature, and 2.38 to 3.97 for consent (all p<0.001).
Conclusion
We found that providing students with real-time assessment and feedback on their medical records increased their skills and confidence in medical records writing.

Keyword

Medical students; Medical records; Clinical practice