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Clinical documentation is an essential skill for practicing physicians, yet many medical students are not prepared for the documentation demands required during residency.1,2 Recent CMS rule changes now allow medical students’ notes to be used for billing.3 Previous studies have shown positive perceptions of medical students whose notes were used in an outpatient setting.4 We utilized Constructivist Learning Theory to frame our work, where students construct their knowledge as faculty and residents facilitate the process.5


To explore if using student documentation for billing impacts student perceptions and experiences during the pediatric clerkship.


Pediatric clerkship students were randomly assigned to one of two inpatient hospitalist teams: Control group students (n=28), whose daily notes were not addended or used for billing purposes, and Study group students (n=42) who wrote notes that were used for billing. After study group students signed the notes, they were addended and cosigned by a resident and subsequently a faculty member who submitted the note for billing. There was no specific feedback structure or documentation curriculum provided to either study arm. We utilized a sequential mixed methods approach (quant+qual), with a survey that included fixed response and open-ended questions, as well as an opportunity to participate in a focus group. Differences in Likert-type questions between groups were assessed with Wilcoxon Rank Sum tests. Open-ended survey responses and focus groups were analyzed using inductive thematic analysis, with consensus among 3 researchers and respondent validation.


Study group students found their experience more valuable, rated the usefulness of feedback from residents higher, and spent more time reviewing edits to their notes than their peers in the control group (p=<0.05).In focus groups and open-ended survey responses, themes from the study group included feeling more useful to the team and receiving more one-on-one feedback. They also reported that there was feedback inherent in reviewing supervisors’ edits to their notes. Control group students reported they focused their time on tasks other than note writing. Both groups reported that the practice of writing notes helped organize their thoughts and plans.


In this exploratory study, use of student notes for billing was associated with feelings of value and enhanced feedback compared to students whose notes were not used. These findings support the use of medical student notes for documentation as a worthwhile educational practice and highlight the need for further study to define curricular interventions that foster development of this essential professional skill.

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Medical Education | Pediatrics

Do I add value? A mixed methods study comparing medical students’ experiences with patient documentation