During residency, physicians refine note-writing skills to meet real-world clinical demands, balancing communication, billing, and medical reasoning amid increasing patient volume.¹,² Patients have become a new audience for clinical notes, requiring physicians to write in a manner that is clear and therapeutic.³,⁴ Patient-centered documentation represents an opportunity to improve transparency and trust while promoting concise, clinically relevant records.

Prior interventions to improve resident note writing have focused largely on inpatient settings, with mixed results. Outpatient documentation—where efficiency and patient-centeredness are particularly salient—remains understudied.⁵⁻⁹

We developed a brief educational intervention designed to enhance outpatient note writing using a simulated encounter involving concern for a sexually transmitted infection. Our objective was to determine whether a single didactic session affected note length or quality, as assessed by faculty ratings.

Family medicine residents (N = 15) attending a scheduled didactic session were invited to participate; 14 consented to analysis of their notes. We developed a rubric assessing readability, redundancy, pertinence, focused physical examination, inclusion of active diagnoses only, clear follow-up, explicit medical decision-making, and inclusion of patient education and care plans in the after-visit summary (AVS). Two faculty members independently rated each note using binary criteria.

Note efficiency was assessed by comparing word counts for note subsections (history of present illness [HPI], review of systems [ROS], physical examination [PE], assessment, and plan).

Residents viewed a mock outpatient encounter presented in three parts: agenda and HPI (video), physical examination (written findings), and assessment and plan (video). They documented the encounter using a Microsoft Forms template, received a concise didactic emphasizing focus, brevity, and patient-centered language, and then revised their notes. Notes were deidentified, randomly ordered, and independently coded by faculty blinded to preintervention and postintervention status.

This study was reviewed and deemed exempt by the Western Michigan University Homer Stryker M.D. School of Medicine Institutional Review Board.

Following the didactic session, documentation changed modestly. Word count analysis demonstrated a significant reduction in physical examination length (P < .05) and a significant increase in assessment and plan length (P < .05), suggesting greater selectivity in examination documentation and expanded clinical reasoning.

Table 1. Word Count and Rubric Scores Before and After Intervention (Within Subjects)

* = Marginally Statistically Significant (0.05<p≤0.10)

** = Statistically Significant (p≤0.05)

Additional Results:

• No significant changes were observed in HPI, ROS, assessment, or total word count.
• Overall rubric scores showed marginal improvement (P = .05).

Faculty ratings demonstrated limited interrater agreement (Table 2). Most notes were rated as readable at baseline, leaving little room for improvement. Redundancy remained common after revision. The most consistent improvement occurred in the “focused physical examination” domain, where several residents made changes aligned with instructional goals.

Table 2. Rubric Ratings by Rater and Item, Before and After Intervention

This note-writing session produced small, targeted changes in residents’ outpatient documentation, particularly in physical examination and assessment and plan sections. However, the overall effect was modest. Persistent redundancy and high baseline readability likely reflect entrenched documentation habits and the structural influence of electronic health record (EHR) templates.

Inconsistent interrater agreement highlights the challenge of assessing note quality using simple rubrics, a limitation noted in prior documentation studies.⁵⁻⁹

Consistent with prior literature, single-session interventions may raise awareness but are unlikely to produce sustained behavior change.⁸,⁹ Limitations of this study include small sample size, single-institution design, and reliance on a simulated encounter. Faculty assessed only one note per resident. P values reflect immediate within-subject change under constrained conditions and should be interpreted cautiously, as documentation quality is influenced by multiple factors, including EHR templates, attending physician preferences, and prior training.

Patient-centered documentation improves transparency and engagement.³,⁴ Written after-visit summaries, readability, and explicit care plans have been associated with improved patient understanding and follow-up adherence.¹⁰ These elements were captured in our rubric, reflecting an effort to assess documentation from the patient perspective, although changes in these domains were modest.

This brief didactic produced small but measurable documentation changes. Sustained improvement will likely require iterative curricula with individualized feedback integrated into clinical training.

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