Medical record-keeping educational interventions for medical students and residents: a systematic review.

ABSTRACT

BACKGROUND: Medical records, encompassing patient histories, progress notes, and more, play a crucial role in patient care and treatment, healthcare communication, medico-legal matters, and supporting financial documentation. OBJECTIVE: Despite their significance, literature suggests inconsistencies in record quality and insufficient formal medical record-keeping education for medical students and residents. The study aimed to identify and evaluate the effectiveness of educational interventions by conducting a systematic review. METHOD: A literature search covering 2003-2023 and review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was undertaken. RESULTS: The literature search identified 44 relevant studies for inclusion. Educational methods, including lectures, feedback, workshops and discussions, addressed different components of the clinical record. The review revealed positive impacts on participant satisfaction, skills and attitudes related to record-keeping. However, some studies reported no significant positive outcomes, emphasising the need for higher-level evidence. Most studies adopted a single-group pretest-posttest design, presenting challenges in control group implementation. The Kirkpatrick evaluation levels were primarily at level 2, with few studies reaching level 3. The absence of studies at level 4 suggested the need for more robust evidence. Studies targeted medical residents more frequently than medical students, with a lack of interventions during the first year of medical education. CONCLUSION: Despite limitations including language bias and methodological variations, the review revealed diverse educational strategies and highlighted the necessity for more randomised controlled trials and studies providing higher-level evidence to enhance clinical record-keeping skills among medical students and residents. IMPLICATIONS Medical record-keeping educational interventions can significantly improve the documentation skills of medical students and residents, thereby enhancing patient care, communication and medico-legal compliance.