Educational Interventions to Develop and Enhance Clinical Documentation Skills in Health Professional Students: A Systematic Review

ABSTRACT Background Clinical documentation is necessary for effective and safe healthcare practice. This paper systematically reviewed educational interventions aimed at developing entry‐level health professional students' clinical documentation skills. Methods A systematic search of electronic...

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Bibliographic Details
Published in:The clinical teacher Vol. 22; no. 5; pp. e70157 - n/a
Main Authors: Wilesmith, Sarah, Mandrusiak, Allison, Lang, Ray, Martin, Romany, Lu, Andric, Forbes, Roma
Format: Journal Article
Language:English
Published: England John Wiley and Sons Inc 01.10.2025
Subjects:
Clinical Competence
clinical documentation
Documentation - standards
education
health professional
Humans
students
Students, Health Occupations
training
written communication
students
training
education
clinical documentation
written communication
health professional
ISSN:1743-4971, 1743-498X, 1743-498X
Online Access:Get full text
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Summary:ABSTRACT Background Clinical documentation is necessary for effective and safe healthcare practice. This paper systematically reviewed educational interventions aimed at developing entry‐level health professional students' clinical documentation skills. Methods A systematic search of electronic databases (PubMed, CINAHL, Embase and Cochrane) from January 2000 to May 2023 was performed, with additional forward and backward citation searching. Inclusion was limited to original manuscripts published in English from January 2000, reporting an experimental or quasi‐experimental design and using objective performance‐based measures. Quality appraisal was conducted using the Medical Education Research Study Quality Instrument (MERSQI), with narrative synthesis of results due to the heterogeneity of outcome measures. Results Of 5313 records identified, 29 studies were eligible for inclusion. The health professions represented were medicine, dentistry, nursing, pharmacy, psychology and veterinary science. Teaching methodologies included the following: didactic instruction; provision of templates, guidelines and/or examples; instructor‐led group discussion; individual or group instructor feedback; near‐peer or peer feedback; self‐evaluation; writing practice activities; worked examples; and response‐to‐stimulus writing activities (written, video or live standardised patient cases). Research quality was low in MERSQI domains of ‘study design’ and ‘validity of evaluation instruments’. Conclusion Several training methods appear valuable in developing student skills in clinical documentation; however, high‐quality evaluation of documentation training interventions is lacking. Future research is recommended to compare existing methods of documentation training and to evaluate training in underexplored healthcare disciplines.
Bibliography:S.W. was supported financially to complete this systematic review by the Australian Government Research Training Program. The other authors have no relevant funding or financial support to disclose.
Funding
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Funding: S.W. was supported financially to complete this systematic review by the Australian Government Research Training Program. The other authors have no relevant funding or financial support to disclose.
ISSN:1743-4971
1743-498X
1743-498X
DOI:10.1111/tct.70157