Improving student documentation using a feedback tool.

BACKGROUND: Medical students are often given non-standardised midpoint feedback and final evaluation on their history and physical examination documentation, despite this written communication being one of the most important aspects of patient care. This study aims to assess the effect of using a standardised feedback tool on overall student documentation performance.

METHODS: A standardised written evaluation form, called the history and physical examination write-up assessment (HAPA) form, was previously developed and published in The Clinical Teacher in 2011. This form evaluates the documentation of student communication, data collection and clinical reasoning, and was used to provide midpoint documentation feedback to one group of medical students, whereas a second group received non-standardised midpoint feedback on documentation. Final written history and physical examination documentation from both groups was then evaluated using the standardised tool to assess the effect of receiving more formalised midpoint documentation feedback using the HAPA form.

RESULTS: The group receiving standardised midpoint feedback using the HAPA form performed significantly better on the final evaluations of their documentation, especially when examining communication and data collection documentation. Performance in clinical reasoning documentation did not demonstrate a significant change between the two groups. Medical students are often given non-standardised midpoint feedback and final evaluation CONCLUSIONS: The use of a standardised evaluation tool, such as the HAPA form, may be associated with improved student documentation. This form provides educators with an effective tool to use when providing feedback and final evaluation of medical student documentation.