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0144 ‘if You Haven’t Documented It – You Haven’t Done It’. The Use Of Simulated Clinical Documents And Notes In An Undergraduate Clinical Skills Curriculum
  1. Judith Caboche,
  2. Robert Johnson
  1. Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, Devon, UK


Context The Francis Report1 and media headlines highlight the importance of accurate medical notes and documentation and their relationship to patient safety outcomes. The Royal College of Physicians (RCP) acknowledge standardised clinical records as fundamental to effective patient care2 The General Medical Council (GMC) provides guidance on required documentation outcomes.2

Documentation teaching was under-represented in the Clinical Skills undergraduate curriculum at Peninsula College of Medicine and Dentistry (PCMD). Student assessments including a domain of ‘documentation’ demonstrated a relative weakness in student competence. Qualitative student feedback also highlighted poor satisfaction with documentation focused teaching sessions.

The aim of the strategy was to improve student learning and behaviours towards documentation. To achieve this, documentation skills teaching and assessment were embedded into a Clinical skills curriculum as implicit and explicit elements.

Methodology Documentation was introduced to all appropriate skills training in Year 1 of a Clinical skills curriculum. Correct documentation was embedded as a learning outcome in all relevant teaching sessions and as a distinct domain in clinical competence testing.

Year 1 students were issued with simulated clinical notes for their pre-clinical training. Preclinical training is simulation based using peers, simulated patients, standardised patients and part task trainers. Students complete and collect documents relevant to all training sessions, e.g. haematology forms for blood sampling, clinical notes recording peer examinations. Students are required to correctly document all actions, findings and requests relevant to each and every training session throughout their preclinical years.

Anticipated results Preliminary analysis demonstrates improved levels of satisfaction for documentation teaching. Documentation skills competence improvement is demonstrated through assessment data.

Potential impact Using simulated clinical notes in undergraduate training may improve contextual learning. Introducing undergraduates to the importance and skills of documentation may help to improve patient safety and outcomes in the long term.

  • Category: Course or curriculum evaluation/innovation/integration

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