Centering the Patient in Student Documentation: A Novel Curriculum and Assessment Rubric for Patient-Centered Note-Writing

PROBLEM: Documentation of a clinical encounter is a foundational skill required of all physicians; however, there is little standardization in documentation skills teaching. In this Innovation Report, the authors describe a novel patient-centered documentation curriculum and assess the efficacy of the curriculum after implementation. APPROACH: Design of the new patient-centered documentation curriculum included creation of a novel rubric to assess patient-centered language (PCL) in student notes built from the IDEA Assessment Tool as well as the development of new faculty and student workshops. The curriculum was introduced at Harvard Medical School between September 2022 and July 2023. OUTCOMES: History of present illness (HPI), physical examination (PE), and PCL were analyzed at early (September-October), mid (February-March), and late (May-June) time points. At the early time point, the mean (SD) student composite score in the PCL domain was 2.53 (0.04), suggesting students were using PCL in their notes some or all of the time. This score was higher than the scores for the HPI and PE domains (2.16 [0.56] and 2.20 [0.52], respectively). Comparing the early and late time points, students had statistically significant improvements in the PCL domain, with a mean (SD) composite value of 2.87 (0.03) at the late time point (P < .001). Statistically significant mean (SD) improvements from the early to late time points were also observed in the HPI (2.16 [0.56] to 2.76 [0.03], P < .001) and PE (2.20 [0.52] to 2.65 [0.51], P = .02) domains. Students demonstrated improvements in the PCL domain when comparing the early and mid (2.53 to 2.76; P < .001) and mid and late (2.76 to 2.87, P = .047) time points. NEXT STEPS: Next steps include modifying the curriculum to the needs of other medical schools and assessing whether the curriculum has a positive impact when adopted more broadly.