Perspectives of undergraduate and graduate medical trainees on documenting clinical notes: Implications for medical education and informatics

Abstract

Ensuring the accuracy of unstructured clinical notes is critical for patient care, research, and quality improvement. Understanding how trainees learn to document these notes and the challenges they encounter are important steps to developing educational and informatics solutions. Authors conducted focus groups to gather the perspectives of 40 medical students (MS) and family and emergency medicine (EM) residents on recording clinical notes in the electronic medical record (EMR). Focus groups were audio recorded, transcribed, and thematically analyzed. Thematic analysis with a deductive approach revealed: a lack of formal education, a shift from information gathering to documenting clinical reasoning with seniority, and barriers to charting development, including variable preceptor expectations and EMR design constraints. Participating trainees report gaps in education around the documentation of notes in the EMR. Future work should explore opportunities to reduce gaps, including more formal education, the creation of specific competencies, and improvements to the EMR.