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Health Information Management Journal

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Documentation of clinical care ª The Author(s) 2016
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DOI: 10.1177/1833358316639448
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A qualitative study of medical
students’ perspectives on clinical
documentation education

Stella Rowlands, BAppSc(MRA), MQIHC, PhD1,2,

Steven Coverdale, MBChB, FRACP, FCSANZ3,
Joanne Callen, BA, DipEd, MPH(Research), PhD, FACHI4

Abstract
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.

Keywords (MeSH)
documentation; education; electronic health records; medical; medical records; students

Introduction hence hospital reimbursement and health service planning

Clinical documentation in medical records can be broadly
defined as any notation made by medical practitioners and
other health professionals relating to a patient’s symptoms,
past history, test results or treatments. Clinical documenta-
tion underpins a number of key activities in healthcare
service delivery and research. Quality clinical documenta-
tion facilitates effective and timely communication and
coordination between members of the clinical team both
internal and external to the hospital and supports safe and
efficient patient care (Gliatto et al., 2009; Hammond et al.,
2012; Kuhn et al., 2015). Second, clinical documentation
supports clinical audit and research aimed at improving
clinical service delivery and patient outcomes (Haghighi
et al., 2014; Russo et al., 2013). Third, clinical documen-
tation provides evidence of care delivery when the practice
of medicine is examined within a legal context (Abdelhak
and Hanken, 2015). Fourth, in relation to activity-based
funding, accurate, comprehensive and timely clinical doc-
umentation supports the function of clinical coding, and
(Chin et al., 2013; Jackson, 2014; Paul and Robinson,
2012). Finally, clinical documentation can act as a
cognitive aid to support medical practitioners’ reasoning
thought processes regarding diagnosis, tests and treatment
(Mamykina et al., 2012).
Documentation in hospital medical records represents a
significant workload for interns and junior medical officers.
An Australian study by Westbrook et al. (2008) reported that
interns spent up to 13% of their Monday to Friday day shift
1
Sunshine Coast Hospital and Health Service, Australia
2
Queensland University of Technology, Australia
3
The University of Queensland, Australia
4
Macquarie University, Australia
Accepted for publication December 22, 2015.
Corresponding author:
Stella Rowlands, Senior Project Officer - Research, Sunshine Coast
Hospital and Health Service, Nambour, QLD, Australia.
Email: s2.rowlands@qut.edu.au
2 Health Information Management Journal
on documentation (excluding discharge summary documen-
tation) and 10% on discharge summary documentation. Ara-
badzhiyska et al. (2013) found that resident medical officers
working in an Australian tertiary teaching hospital spent
43.8 min per 10-h night shift on documentation. Studies
undertaken in the United States by Alromaihi et al. (2011)
found that residents spent 32% of their day on paperwork;
similarly, Oxentenko et al. (2010) reported that 67% of res-
idents spent more than 4 h per day on documentation. Clin-
icians have also been reported to spend as much time on
documentation as they do in direct patient care (Ammer-
worth and Spotl, 2009; Christino et al., 2013). Given the
time spent on clinical documentation, it is essential that
studies explore the quality of education in this area to ensure
clinicians’ time is utilized efficiently.
In Australia, junior doctors are usually responsible for
documenting care delivery in hospital medical records. The
scope of the clinical documentation performed by junior
doctors generally includes the completion of progress notes,
medication orders, test orders, discharge summaries as well
as specialized forms based on the clinical speciality. The
expectation that the least experienced members of the clin-
ical team will complete documentation could be considered
a risk and further highlights the need for adequate education
of medical students. In February 2011, the Medical Deans of
Australia and New Zealand published a report titled Devel-
oping a Framework of Competencies for Medical Graduate
Outcomes (Carmichael and Hourn, 2011), and unfortunately
this document failed to include any attributes related to writ-
ten communication. An Australian study by Oates et al.
(2014) found that only 6.2% of an intern’s 40-h week is
spent receiving teaching (both formal and informal). Given
the scope of the teaching provided to interns, it may be
presumed that clinical documentation was a minor feature
of the program. This implies that if we do not educate med-
ical students in clinical documentation it is probable that this
education will not occur in their internship year either. This
conclusion is supported in the key recommendations from a
recent position paper by the American College of Physicians
(Kuhn et al., 2015). The need to improve medical education
in order to prepare clinicians for taking responsibility in
providing complete, accurate and concise clinical documen-
tation was identified (Kuhn et al., 2015).
To date, limited studies have assessed the adequacy of the
medical curriculum on clinical documentation (Gliatto
et al., 2009). Gliatto et al. (2009) explore through a review
the value of medical student documentation, the issues that
make student documentation problematic and the impact of
limiting medical student documentation. In particular, they
note that policy and research to support best practice in the
teaching of written communication to medical students are
lacking (Gliatto et al., 2009). Asch and Weinstein (2014), in
a perspective on graduate medical education, referenced an
incidental finding of the Institute of Medicine’s (2014)
report on the governance and financing of graduate medical
education that highlights the lack of an evidence base to
inform future decisions. In particular, Asch and Weinstein
(2014) raise the following issues in relation to medical edu-
cation – ‘valid and feasible measures of training success
need to be defined’ (pp. 794–795) and ‘we need to examine
changes to the structure and content of medical education’
(pp. 794–795). Interestingly, to our knowledge there have
been no studies that have explored the perspectives of med-
ical students in relation to clinical documentation education.
The aim of this study was to determine medical stu-
dents’ perspectives of their education in the documentation
of clinical care in hospital patient’s medical records.
Method
A qualitative method was employed to gain an in-depth
understanding of medical students’ perceptions. The study
was undertaken in a hospital-based clinical school of an
Australian university. The study hospital medical record
is primarily paper based, with some specific electronic
clinical information systems in use such as an electronic
discharge summary. In both 2012 and 2013, there was an
average of 28 fourth-year medical students attached to the
clinical school. Student numbers at the clinical school var-
ied with some students permanently rostered to the site for
the year, whilst others spent only one rotation at the site.
A letter was sent to all fourth-year medical students advis-
ing them of the study and seeking volunteers to be inter-
viewed. The volunteers were requested to contact the
principal investigator (S.R.) by email should they wish to
participate in the study. A follow-up email was sent to the
students in both years to remind them of the study. As the
study did not commence until late in 2012, it was not pos-
sible to recruit the desired number of participants and there-
fore the recruitment was continued in 2013. Recruitment
ceased when saturation was reached and no new informa-
tion was arising from the interviews. Fourth-year medical
students were selected for the study population as it was the
final year of their education prior to undertaking their
internship year. Participation in the study was voluntary.
Following initial contact by email the principal investigator
S.R. organized a date and time to interview the students in
an interview room on the hospital campus. The students
were provided with an information sheet prior to the inter-
view and were required to complete a study participation
consent form. For the purposes of this study, clinical doc-
umentation was defined as the preparation, composition
and documentation of admission, discharge or daily prog-
ress notes on hospital patients by medical students. The
interviews were completed face-to-face by the principal
investigator S.R. between April 2012 and September
2013. The interview questions (Figure 1) sought to explore
participants’ perceptions of their current education on clin-
ical documentation; how the curriculum could be
improved; the support provided by clinicians in relation
to documenting clinical care; and the importance of feed-
back in the development of clinical documentation skills.
Interviews were audio taped and transcribed by the prin-
cipal investigator S.R. Three researchers (S.R., J.C. and
S.C.) independently reviewed the de-identified transcripts
using a grounded theory approach (Glaser and Strauss,
1967). Each researcher independently read, analysed and
reflected on the data to arrive at a set of codes based on
Rowlands et al.
Interview questions:
1. Please describe the formal education you have received on
clinical documentation.
2. How would you rate the adequacy of clinical
documentation in the curriculum as compared with your
experience in documenting clinical care within the context
of patient care? Could the curriculum be improved in any
way?
3. What level of support do other clinicians provide to you,
when you are documenting clinical care?
4. How important is feedback on clinical documentation?
Figure 1. Interview questions on clinical documentation
education for medical students.
predefined categories linked to the interview questions.
Triangulation of analysis was achieved as the three
researchers (S.R., S.C. and J.C.) then met and undertook
further discussion, reflection and analysis to arrive at a final
set of themes and subthemes. Divergent views were
resolved during this discussion with the lead researcher
(S.R.) making the final decision.
Ethics approval for the study was obtained from the
Human Research Ethics Committees of The University of
Queensland and Queensland Health.
Results
Demographics of participants
Fourteen medical students were interviewed from a popu-
lation of 28. Six fourth-year medical students were inter-
viewed in 2012 and eight fourth-year medical students
interviewed in 2013 (n ¼ 14). Eight (57%) were female
and six (43%) male, with an average age of 26 years (range
23–32 years). Most participants had undertaken a science-
based undergraduate degree; one had completed a com-
bined science and law degree and another was currently
completing a combined science and medical degree.
Themes
Themes relating to the quality of clinical documentation
education provided to medical students and subthemes rep-
resenting the respondents’ perceptions of clinical docu-
mentation education are presented in Table 1.
Theme 1: Formal clinical education documentation is limited.
Most medical students reported that formal clinical docu-
mentation education was limited. Formal education for the
purpose of the study was defined as lecture or tutorial style
education. Most references to formal education made by
the participants related to education in the first and second
years of their medical degree, which is primarily university
based. Some students did make reference to formal educa-
tion provided as a component of the ‘Linked Curriculum’
delivered in third and fourth years when medical students
are primarily hospital based. The Linked Curriculum con-
sists of a mix of scenario-based tutorials from hospital staff,
associated with the hospital-based clinical school, aiming
3
to prepare the student for the intern year. Representative
quotes reflecting this theme are presented in Table 2.
The majority of students had limited recall of any clin-
ical documentation education during first and second years.
Of those few students that did recall the education, one
student could recall lectures in the second year but indi-
cated that the detail had faded by the third year. Other
students described the lectures as focusing on documenta-
tion from a legal and communication perspective rather
than on how to document. A number of students did recall
completing a ‘long case’ that was submitted for assessment.
The perceived benefits of completing a long case varied,
with some students indicating that whilst a template was
provided, they had little knowledge of what they were
doing and received limited feedback. However, other stu-
dents found it beneficial, as it was the first exposure to
documenting in the clinical setting. The majority of stu-
dents described some education on clinical documentation
in their third or fourth year. However, attendance at these
tutorials was not mandatory.
In summary, most respondents felt they had received
either no or limited formal education in clinical documen-
tation and therefore felt ill-prepared to document clinical
care. There were two students who felt that the curriculum
had prepared them to document clinical care. One student
described the documentation of clinical care as being non-
intuitive and the health record as a mystery as they did not
understand the headings and acronyms, especially in the
specialty wards. The description of the inadequacy of the
curriculum was set against the backdrop of the expectations
of the senior doctors. A number of students described being
handed the health record and being asked to write the notes
without any assessment of their knowledge of clinical doc-
umentation nor their competency. The students considered
that the senior doctors presumed that they had received
adequate education in clinical documentation. One student
described seeking out another doctor and asking them for
assistance. The strategy used by a second student was to
review and use the notes written by others as a guide.
Theme 2: Concerns regarding ‘on-the-job’ clinical documentation
education. Medical students’ concerns regarding on-the-job
clinical documentation education (which was further cate-
gorized into three subthemes: (a) education varies between
teams, (b) lack of feedback from senior clinicians and
(c) importance of feedback for medical students’ learning
of disease processes and treatments) are represented in
Tables 3, 4 and 5.
Subtheme (a): Education varies between teams. Most stu-
dents considered they learnt how to document on the job,
and junior doctors provided most of this training. Informal
tutorials on clinical documentation were described by a
number of students. Learning on the job was described as
varying from team to team, and uptake of skills was con-
sidered to improve if the student volunteered to complete
the documentation. Variability was noted between teams in
relation to support for medical students in completing the
documentation. How busy the team was, was also
4 Health Information Management Journal

Table 1. Themes and subthemes relating to medical students’ perceptions of education in clinical documentation identified
from the interviews.

Themes Subthemes

Formal clinical documentation education is limited

Medical students’ concerns regarding on-the-job clinical
documentation education
Medical students’ perspectives on how clinical documentation
education could be improved
(a) Education varies between teams
(b) Lack of feedback from senior clinicians
(c) The importance of feedback for medical students’ learning of
disease processes and treatments
(d) Timing of clinical documentation education
(e) Importance of on-the-job clinical documentation education

Table 2. Representative quotes from medical students regarding formal clinical documentation education during their training.

Medical student quotes

‘You’re always told it is important but yet we don’t have any teaching on it’.
‘Written communication is not at the foreground in medical education whereas oral communication is, good coverage of empathy, and
breaking bad news, and body language but not written communication. I think doctor’s don’t realise it should be part of their skills set,
don’t think it is an expectation of medical students when they graduate to be good at written communication – because the ‘older
guard’ don’t have those expectations so it has not been passed down’.
‘ . . . inadequate to say the least I think. I’m not sure what other medical schools do but you know it takes a long time to figure this stuff
out. It’s not as intuitive as people think and especially when they expect us to kind of know how to do some of this stuff in second
year. There were cases that we had to do, go to the hospital, interview patients and write up the cases. And then look at their chart
and all that sort of stuff. And we would read the chart and we would all just kind of scratch our heads together and look at all the
acronyms and look at it all the time, at the headings and not even know what the hell we were reading. Especially if you were in a
specialty ward, you know. I think when you are rostered to the General Medicine and General Surgery rotations you kind of have
some idea, but once you get into the specialties the acronyms and kind of, just even how they set out’.
‘It’s intimidating to go onto ward rounds and I think a lot of the more senior doctors expect you to have had that teaching. So they hand
you the chart or whatever and go fill this out and turn it in, and you have no idea how to do it. So it’s basically you know, you grab one
of the doctors you feel comfortable with and go how do you actually fill this out’.
‘So you can fake your way or like, look what other people have done and stuff like that. But yeah the curriculum itself is pretty limited
considering how often you end up doing it and what’s sort of expected of you’.
‘Particularly this year I found it to be quite difficult because the only sort of training we had or education was in taking a long case and
you don’t do that on a daily basis in the wards’.
‘There is a disconnection between when we are taught about how to take notes and when we need to do that. It might only be six
months or whatever but because of the disconnection, it does seem like a lot of teaching can be forgotten’.

Table 3. Representative quotes from medical students on their concerns regarding clinical documentation education by
subtheme (a).

Subtheme (a): Education varies between teams

‘And that’s how we’ve learnt paperwork as much as we have learnt everything else’.
‘I guess I have learnt more from the junior doctors and staff on ward rounds and just informally’.
‘Other than that it’s been a bit of picking up skills from other clinicians, especially junior clinicians whilst we are on the wards. I’ve always
had the sense that they didn’t really know what they were doing either and they were teaching me, ignorant leading the ignorant. So I
hoped that we were doing the right thing’.
‘I guess documenting is part of the learning experience, so getting some experience in that is important. But at the end of the day as a
med student I would rather sort of observe what the consultant does as opposed to worry what he is saying, try to write it down on a
piece of paper . . . So I think, when I am asked to do it I am certainly happy to do it. And if there is no registrar or intern, they are off
doing something else, I am very happy to take the chart and document whatever the registrar or consultant wants to put down. But
most of the time I wouldn’t go off and say can I please write this up’.
‘After a while, they just, they especially the senior clinicians they just kind of bark orders and whatever and you are just supposed to
catch it all and know which priority it is and which problem list it’s addressing. And how to kind of you know, do it all’.
‘If we were given more encouragement or support to be a part of that clinical documentation as a medical student then I think it could
facilitate a lot better learning in the wards. Just because then it solidifies when you’re doing something bedside and then go to write it
down, it’s just if the process is more, what do you call it, in modes of learning’.

mentioned as a factor which impacted on clinical documen- until they felt settled within a team before volunteering to
tation education. Many students reported that they were document. Some students considered it was a ‘balancing
more likely to be encouraged to document on medical act’ between listening from the perspective of learning as
teams. However, a number of students reported waiting opposed to listening in order to complete the documentation.
Rowlands et al. 5

Table 4. Representative quotes from medical students on their concerns regarding clinical documentation education by
subtheme (b).

Subtheme (b): Lack of feedback from senior clinicians

‘As a junior doctor and especially as a medical student, often you will write a lot more not knowing what’s relevant to the patient
because you don’t understand the disease process as well as the more senior doctors. So if they could provide that feedback that
would be fantastic’.
‘I found that when I write ward round progress notes they’ll often just go – yep – and sign off at the end, without actually reading it’.
‘Because they need to countersign, although a lot of them aren’t even proactive about that. Like, a lot of times you need to chase them,
chase doctors down to countersign’.
‘For the most part they’re happy to just countersign without necessarily checking your work which is, you know, it’s good because it
shows like that they, they at least have confidence that you’re doing what you should be and hopefully that you are documenting what
they have said and stuff like that. But it would be a lot more useful if they went through and said you know, like you could have said
this there’.
‘Just take for example like, one team that I was on earlier this year, one of the medical specialties team. One particular registrar, she
would read every single note that I would write before she would co-sign and she would always and generally most of the time add
something or take something away, or just change something that I had written certainly. Whereas this – one of the senior house
officers that would sign against it, she would generally at the start she would read my notes but generally towards the end of the
rotation she was happy’.
‘A lot of the times, probably fifty percent of the time they will glance over it if anything, they will just look at the plan that I’ve written
assessment and plan which is the end of the note and they’ll almost never read anything else’.
‘To be left alone doing that documentation I think would be dangerous’.
‘And I think that really highlights the importance of being able to do it (learn how to document) informally as well because I can make
these mistakes now when someone else is reading and doing it instead of making these mistakes next year’.
‘If they could provide feedback I think – you know – we’d obviously be a lot better at documenting and the intern would be a lot better
at guiding when we’re senior doctors, future students and junior doctors on track’.

Table 5. Representative quotes from medical students on their concerns regarding clinical documentation education by
subtheme (c).

Subtheme (c): The importance of feedback for medical students’ learning of disease processes and treatments

‘If they add something in the physical exam or the history then I take a note and think that is obviously important if it’s been added and
then make a mental note to try and ask about it next time you see a patient with a similar thing’.
‘I definitely think it would because often I will write something that won’t be relevant to the patient. If they can say – why did you write
that, why did you think that was important? And often they will do things that I hadn’t thought of doing, and then you go, well why
specifically did they look for or want me to write, document that down. And then you go back to the whole disease process and read
into it. So if they did give you that feedback I think we would learn a lot more about the different diseases and about what’s relevant to
look for when someone presents with a certain complaint’.
‘A lot of the times I learn the most when they critique me you know and I have been on a couple of teams where the registrars have
been extremely diligent and actually you know, come up to me afterwards and said do you understand why we did this in this order?
Do you understand why this is the plan or which part of the plan related to what problem? And actually no I have no idea and just like
a lot of the interns, we are just you know, we are just a kind of a secretary with a stethoscope, we’re just taking notes. We’re an
admin person’.
‘As a junior doctor and especially as a medical student, often you will write a lot more not knowing what’s relevant to the patient
because you don’t understand the disease process as well as the more senior doctors. So if they could provide that feedback that
would be fantastic’.
‘I think it just varies differently between different doctors how much feedback and how much they have trust in the student’. Good
performance was reinforced by positive feedback, trust and further exposure. One student noted – ‘that if you are not getting any
feedback . . . not actually learning’.

Whilst one student described on-the-job training as being a
positive experience, the student also described the limitations
of this mode of training should a student have a poor clinical
experience or undertake overseas terms. One student
described being assigned to a team where the consultant pre-
ferred to complete their own documentation. On the other
hand, a number of students reported that some specialist med-
ical officers expected the student to know how to document
and therefore there was limited on-the-job training provided.
Subtheme (b): Lack of feedback from senior clinicians. The
majority of students saw feedback as being an integral part
of their education. Lack of time was seen as a factor influ-
encing feedback. One student reported having limited
knowledge of how their documentation competence was
established. The level of feedback and trust in the ability
of the medical student to document clinical care was
reported as varying from doctor to doctor.
The countersigning of medical student entries in the
health record by a registered medical practitioner is accepted
practice in Australia. However, many students reported that
they had to chase a medical officer to sign their entry.
Additionally, students reported that the medical officer
did not always review the entry before countersigning. A
6 Health Information Management Journal

Table 6. Representative quotes from medical students on how clinical documentation education could be improved.

Subtheme (d): Timing of clinical documentation education

‘And I would say that you know documentation is probably one of the basics – so. I would really, . . . I would really like to see some
teaching in this because I think you are just thrown in the deep end at the start of third year and people are like take a history and
write it all up and come discuss your findings with me. And at the start of third year you are like, . . . my first day in a hospital I
forgotten what constitutes a history you know how do I do that examination. And then how to write it all in and make it seem, you
know not like a story because when you first start off you are just kind of writing essays you don’t realize that’s not really that’s not a
very good use of your resources and time writing essays about every single patient’.
‘I think the entire Linked Curriculum series should be inclusive of third year’s and fourth year’s. Just because if you are going to learn
something that – clinical note taking or coding or anything in third year you are going to forget a lot of it but in fourth year certainly –
it’s a big gap in between’.

Subtheme (e): Importance of on-the-job clinical documentation education

‘The formal education should be supplemented with practical experience on the wards’.
‘I mean even like probably half an hour, just someone to go through like and show different examples how, how people go, different
ways you can go about documenting things and what’s important, what are the important bits of information when you go around on
a ward round’.
‘But the Linked Curriculum I definitely think is well organised and generally well presented. As long as the presenter makes some effort
to involve the student’.
‘And I would say that you know documentation is probably one of the basics – so. I would really, . . . I would really like to see some
teaching in this because I think you are just thrown in the deep end at the start of third year and people are like take a history and
write it all up and come discuss your findings with me. And at the start of third year you are like, holy . . . my first day in a hospital I
forgotten what constitutes a history you know how do I do that examination. And then how to write it all in and make it seem, you
know not like a story because when you first start off you are just kind of writing essays you don’t realize that’s not a very good use of
your resources and time, writing essays about every single patient’.

number of students also reported that initially their entries
were read prior to countersigning, but that over time their
entries were countersigned without being read. There was a
perception by some students that if the entry is signed but
not read, the team member must be confident in their ability
to document clinical care. Students also thought that
because a particular case had been discussed then it was
considered they should be able to document without
review. A number of students expressed concern regarding
the failure of a more senior medical practitioner (as
opposed to an intern or junior medical officer) to review
their notes before countersigning.
Subtheme (c): The importance of feedback for medical
students’ learning of disease processes and treatments. Many
students saw the failure to read medical student entries
prior to countersigning and therefore to receive feedback
as a lost opportunity for the student to learn what to docu-
ment and to understand more about the patient’s condition
and management. In circumstances where the entries were
countersigned, it was reported as a positive learning expe-
rience when changes were made and discussed.
Theme 3: Perspectives on how clinical documentation education
could be improved. Representative quotes on medical stu-
dents’ perspectives on how clinical documentation educa-
tion could be improved (which was further categorized into
two subthemes: (d) the timing of clinical documentation
education and (e) the importance of on-the-job clinical
documentation education) are included in Table 6.
Subtheme (d): Timing of clinical documentation education.
Many students considered that clinical documentation edu-
cation should occur at the beginning of the third year, with
a number of students recommending a refresher at the
beginning of the fourth year. Several students considered
that the university-based curriculum could be improved;
however, one student described the lack of context of the
formal education as being an issue for assimilation of infor-
mation. The opt-in format of the education provided in the
third and fourth years within the Linked Curriculum
(hospital-based Intern Preparation Program) was seen as a
problem, with a number of students stating that clinical
documentation education should be mandatory.
The students recommended the education occur in a
number of formats including lectures, work examples,
online modules, interactive sessions and teaching rounds
on documentation.
Subtheme (e): Importance of on-the-job clinical
documentation education. Whilst the students made recom-
mendations in relation to formal education, they also con-
sidered practice to be the key to learning how to document.
Discussion
Our results have reported the first findings (to the best of
our knowledge) related to Australian medical students’ per-
ceptions of their education in clinical documentation. We
found that medical student education on clinical documen-
tation was primarily delivered on the job rather than in
formal lectures and tutorials. Delivery of clinical documen-
tation education on the job was reported to be problematic,
frequently delivered by the most junior member of the team
and with limited feedback provided by more senior clini-
cians. Where medical education was delivered through a
curriculum-based program, the students considered the
education was inadequate and lacked context, particularly
in the first and second years, where there were no
Rowlands et al.
opportunities to gain practical experience in documenting
clinical care. Respondents perceived a strong relationship
between the opportunity to document clinical care, to dis-
cuss with senior clinicians what to document and what to
exclude, and the acquisition of their clinical knowledge.
They recommended the focus of formal clinical documen-
tation education be moved to the third and fourth years of
their training.
Our study supports the relationship between the devel-
opment of skills in clinical documentation and the acquisi-
tion of clinical knowledge by medical students. Review of
clinical documentation by senior clinicians and feedback to
medical students has a secondary benefit as a trigger for a
discussion on patient management. The results of our study
are supported by McCarty et al. (2005), who consider that
the development of note-taking skills is essential to the
ability to document clinical findings and demonstrate clin-
ical reasoning. Ferenchick et al. (2013) in their study mea-
suring student performance on documentation of patient
care in an electronic medical record (EMR) reported a low
but statistically significant correlation between EMR errors
and the students’ subsequent assessment on professional-
ism and end-of-year observed structured clinical examina-
tion scores for communication and history taking.
Schenarts and Schenarts (2012), in assessing the impact
of the EMR on medical student education, identified a
correlation between documentation and clinical reasoning.
In contrast, Christino et al. (2013) reported that trainees
considered the quality of their education was diminished
due to the requirements to document. However, on the basis
of the results of our study it could be considered that the
opportunity to document is a lost opportunity for education
on the clinical process and patient management. It could be
claimed that discussing what to document, and why it is
documented or not, is an opportunity for the medical stu-
dent to learn. The results of our study are supported by
Gliatto et al. (2009) who suggest that learning to ‘record’
provides a framework for assessing skills such as history
taking and enables students to organize their thoughts and
examine their own reasoning processes.
Medical students in our study reported that feedback on
their documentation was variable. This result is supported
by Oxentenko et al. (2010) who reported, in a study of
16,402 internal medicine residents and 235 program direc-
tors, that feedback was received less than 50% of the time,
and this result was consistent between residents and pro-
gram directors. However, he also reported that whilst feed-
back was limited, the importance of feedback was noted to
be at least of moderately high importance by 73.2% of
program directors and 58% of residents (Oxentenko
et al., 2010).
Within Australian universities and internationally, there
is ongoing debate on how to educate medical students.
Methods such as teacher-led learning, problem-based
learning, case-based learning, lectures, tutorials, on-
the-job training, dissection, computer-assisted learning and
simulation are used to educate medical students (Bokey
et al., 2014). In our study it would appear that both the
lecture and on-the-job formats of clinical documentation
7
education are not meeting the needs of medical students.
In our study, we have identified that medical students are
essentially responsible for their own education on clinical
documentation as the lectures are held too early and on-
the-job training is problematic. Many students have, how-
ever, identified the relationship between documentation
and the development of clinical knowledge, and have sug-
gested that tutorials in clinical documentation should be
held at the beginning of the third and fourth years. Consid-
eration should be given to utilizing the opportunity of com-
bining and the acquisition of clinical knowledge. It is
proposed that a number of clinical scenarios be presented
in either a tutorial or a simulated learning environment and
that the student is required to document the patient man-
agement using a structured format (e.g. ‘SOAP’ – subjec-
tive, objective, assessment and plan). A peer-to-peer
evaluation process of the quality of the documentation is
then recommended, by critiquing what each student has
documented against the clinical scenario.
It is important to research clinical documentation as the
use of electronic health records broadens and deepens
(Schiff and Bates, 2010). There needs to be more under-
standing of where current documentation education is
deficient so improvements can be made to ensure elec-
tronic clinical documentation meets the current and future
needs of health professionals, patients and other users of
health data (Callen, 2014; Embi et al., 2013). Increas-
ingly, patients are accessing their electronic health data
and participating in shared decision-making and self-
management of chronic conditions that also focus atten-
tion on the quality and role of clinical documentation
(Morrison et al., 2014).
Limitations
It should be noted that this study is qualitative and from one
medical school, and therefore is not generalizable to the
broader population of medical students in Australia. How-
ever, the qualitative methodology provides rich informa-
tion on medical students’ perspectives in relation to what is
lacking in current education regarding clinical documenta-
tion in the patient’s medical record.
Conclusion
Documentation remains a major, and essential, compo-
nent of the medical practitioner’s working day. Medical
students perceive that there is a relationship between doc-
umentation and their learning processes. It is essential that
on-the-job training with feedback in clinical documenta-
tion be provided to ensure accurate, safe, succinct and
timely clinical notes. With the advent of EMRs, compre-
hensive and timely provision of education in documenta-
tion of a patient’s history, treatment and progress is
particularly important.
Acknowledgements
The authors wish to acknowledge the contribution of the medical
students who participated in this study.
8 Health Information Management Journal
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship and/or publication of this article: This
research was funded in part by the Wishlist Sunshine Coast Health
Foundation.
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