PCRF Research Alert: Developing Documentation Competencies

Each month the Prehospital Care Research Forum combs the literature to identify recent studies relevant to EMS education practices. 

DeLeon S, Mothner B, Middleman A. Improving student documentation using a feedback tool. Clin Teach, 2018 Feb; 15(1): 48–51. 

EMS education standards call for paramedic student competency in documentation and medical report writing by the time of graduation. But how do programs ensure competency? With the move from paper to electronic health records (EHRs), medical informatics and data-driven processes depend on accurate documentation. Instructional guidelines and EMS textbooks include segments on narrative writing using standardized formats such as SOAP or CHART and general guidelines for accurate documentation; however, standardized tools to assess development of documentation competency are lacking. 

This is not the case just in EMS education. Surveys from medical colleges reveal inadequate student access to records, due in part to overly rigid interpretations of HIPAA privacy laws. As a result the American Association of Medical Colleges (AAMC) in 2014 published critical core competencies medical students should possess on their first day of residency. These include documentation of clinical encounters. This prompted medical education programs to develop standardized tools that evaluate students’ EHR competency.

One such tool is the history and physical examination write-up assessment (HAPA), a standardized tool developed by expert consensus, pilot-tested for reliability, and designed to assess medical student documentation during a pediatric clerkship. The HAPA includes three domains: written data collection; evidence of clinical reasoning; and clear, chronological communication of the patient’s story. Each domain contains specific criteria totaling 38 items of evaluation. 

Researchers Stephanie DeLeon, MD; Brent Mothner, MD; and Amy Middleman, MD, from the University of Oklahoma Health Sciences Center and Baylor College of Medicine, examined the effect of using the HAPA as a formative tool on the final evaluation of student documentation in medical students during a pediatric clerkship. Two groups of 39 medical students participated. Group 1 (n=20) was the control group, receiving nonstandardized verbal and written feedback from an on-service teaching physician at the midpoint of a two-week pediatric clerkship. Group 2, the intervention group, received midpoint verbal and written feedback from the on-service teaching physician using the HAPA form as a standardized feedback tool. 

At the conclusion of the clerkship, blinded evaluators examined documentation of the 39 de-identified students using the HAPA tool to score performance. Results showed that documentation from students in the control group did not improve from the midpoint to the final evaluation, in contrast to the intervention group, which significantly improved documentation performance. Interestingly, the clinical reasoning scores were not significantly different between the groups, suggesting that processes such as differential diagnosis, assessment planning, and management plan documentation depend on other factors, like supervised experience and verbal formative feedback. 

One criticism of the study could be that the students in the intervention group were given the criteria and therefore more likely to improve. But remember the HAPA contains information that providers agreed is essential to a patient care record, and medical training was already included in didactic training on patient documentation. The difference was that in the intervention group, students received standardized feedback. I think this study showed the importance of the deliberate use of an evidence-based teaching tool to provide meaningful formative and summative feedback to students as they develop and achieve documentation competency. 

As we develop minimum competencies in our EMS programs, maybe it’s time we start working together on evidence-based educational tools we can use to assist EMS students in developing documentation competency. 

Megan Corry, EdD, EMT-P, is the program director and full-time faculty for the City College of San Francisco paramedic program and on the board of advisors of the UCLA Prehospital Care Research Forum.