ArticleAdvances in health sciences education : theory and practice2023
Documentation as composing: how medical students and residents use writing to think and learn.
Article in Advances in health sciences education : theory and practice, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 13 papers, 1 of them a synthesis that pooled it.
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
13 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Educational Interventions to Develop and Enhance Clinical Documentation Skills in Health Professional Students: A Systematic Review.The clinical teacher · 2025Pooled it
- Student Competency in Outpatient Documentation: Insights From the 2025 CERA Clerkship Directors Study.Family medicine · 2026Article
- Artificial Intelligence Scribes in Psychiatry Training.Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry · 2026Article
- Construction and application of an intelligent tutoring system for resident physicians' medical record writing based on large language models.BMC medical education · 2026Article
- Impact of an Ambient AI Scribe on Medical Student Objective Structured Clinical Examination Notes: Nonrandomized Clinical Trial.JMIR medical education · 2026Article
- Accuracy of large language model transcription of simulated physician-patient verbal interactions.BMC medical informatics and decision making · 2026Article
- In Support of Meaningful Assessment and Feedback: A Study of Clinical Reasoning Tasks Used in Ambulatory Case Reviews.Perspectives on medical education · 2026Article
- Communication Surrounding Treatment Preferences for Older Adults With Dementia During Emergency Medical Services Response.Journal of the American Geriatrics Society · 2026Article
- Implementation of Ambient AI Scribes in Hospitals: Lessons for Healthcare Leadership, Governance, and Change Management.Journal of healthcare leadership · 2026Review
- Enhancing Resident Note Documentation: A Quality Improvement Initiative to Accurately Capture Patient Complexity.American journal of medicine open · 2025Article
- Harnessing the potential of large language models in medical education: promise and pitfalls.Journal of the American Medical Informatics Association : JAMIA · 2024Review
- Reasoning on Rounds: a Framework for Teaching Diagnostic Reasoning in the Inpatient Setting.Journal of general internal medicine · 2023Article
- Beyond Words: Addressing Ethical Issues in Clinical Documentation through Medical Education.The Hastings Center reportArticle
Corrections and comments
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Authors and funding
3 authors.
Funding
Abstract
Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.
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What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.