A Patient-Centered Documentation Skills Curriculum for Pre-clerkship Medical Students in an Open Notes Era
A new paper published in MedEdPORTAL details the design of a new “open notes” curriculum at Harvard Medical School. The curriculum was designed to prepare the next generation of learners to employ clinical notes as a tool to communicate with patients, introduces key ethical considerations, and details how documentation can enhance or harm therapeutic relationships with patients. Learners were taught note-writing skills through a patient-centered lens, with a special consideration for the impact on patients and providers. An emphasis was placed on using bias-free language in constructing a medical note.
While the longitudinal impact of the curriculum remains to be seen, patient-centered documentation skills should be an integral part of documentation education for clinicians. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.
This work is part of the Educating Young Health Professionals initiative at OpenNotes, which is funded by the Josiah Macy Jr. Foundation with a matching gift from Kate and Arnold Schmeidler. The curriculum is co-led by Anita Vanka, MD, and Katherine T. Johnston, MD–both Assistant Professors of Medicine at Harvard Medical School, and Course Directors of the Practice of Medicine.
Read the full paper here.
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About OpenNotes
OpenNotes is an international movement spreading, studying, and teaching transparent communication among patients, families, and clinicians. When clinical notes are shared with patients, they are called ‘open notes.’ OpenNotes is motivated by evidence indicating that when health professionals offer patients and families ready access to clinical notes, the quality and safety of care improves. OpenNotes is a not-for-profit research lab based at Beth Israel Deaconess Medical Center, a major Harvard Medical School teaching hospital.
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