Documentation of clinical care in hospital patients’ medical records

BACKGROUND: Clinical documentation is essential for communication between health professionals and the provision of quality care to patients. OBJECTIVE: To examine medical students' perspectives of their education in documentation of clinical care in hospital patients' medical records. METHOD: A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university. RESULTS: Several themes reflecting medical students' clinical documentation education emerged from the data: formal clinical documentation education using lectures and tutorials was minimal; most education occurred on the job by junior doctors and student's expressed concerns regarding variation in education between teams and receiving limited feedback on performance. Respondents reported on the importance of feedback for their learning of disease processes and treatments. They suggested that improvements could be made in the timing of clinical documentation education and they stressed the importance of training on the job. CONCLUSION: On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes.