Teaching medical students the art of the 'write-up'.

ABSTRACT

BACKGROUND: The creation of a complete 'write-up' continues to be essential to the clinical learning experience for medical students. The ability to document a clinical encounter is a key communication skill and Core Entrustable Professional Activity for entering residency. METHODS: We developed a guide to the comprehensive write-up, a grading rubric, and a videotaped encounter with a standardised doctor and patient. Second-year medical students created a write-up based upon this encounter, which was then peer-reviewed in a small group writer's workshop session. The students were later required to submit a write-up, based upon a real patient encounter, to the course directors for a grade. All write-ups (n = 185) were graded by the course director. Fifty-one were independently graded by a second course director. These grades were compared with the 175 student write-ups from the previous year. The ability to document a clinical encounter is a key communication skill … for entering residency RESULTS: The average grade for student write-ups was 86 with a standard deviation of 9, compared with an average of 75 with a standard deviation of 17 for the year prior to the introduction of this session (p < 0.001). The average score given by a second rater was 83 with a standard deviation of 11, indicating a high level of agreement and internal consistency. DISCUSSION: These tools were easy to use and well received by faculty members and students, and the quality of student write-ups significantly improved after the introduction of the session. The grading rubric demonstrated high inter-rater reliability, indicating that this can be adapted and used by others for instruction and assessment.