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Medical documentation as a reflection tool to help learners reduce clinical errors of omission.

Purpose: To evaluate the impact of medical documentation in reducing errors of omission for senior medical students.


Background: New residents are expected to quickly respond to changes in their patient’s medical status and this urgent cognitive shifting can increase the chance of medical errors.  A dual-processing model has been described as a framework for error mitigation. Type 1 thinking is automatic and involves heuristics. Type 2 thinking involves more reflection and critical thinking. We hypothesized that if required to document urgent scenarios students would “slow” down and thereby think more critically about the encounter.


Methods: Sixteen medical students enrolled in a residency preparation course participated in a simulated paging curriculum involving an urgent pre-eclampsia patient.  Students responded to a page from a Standardized Registered Nurse (SRN), gathered additional history, and discussed their management plan. Students were then instructed to document a brief note. Clinical performance was scored based on weighted checklist items. A phone score (number of items completed in the phone encounter) and combined score (number of items from combined phone and document) were calculated and compared.


Results: The combined scores were significantly higher than phone scores (86% vs 75%; p=0.00097). Critical management items, such as starting Magnesium, administering anti-hypertensive medication, and assessing labor progress were all significantly more likely to be performed when a note was documented after the encounter. 


Discussions: Documentation in urgent patient care scenarios can improve the management plans for medical students by allowing “type 2” thinking. This gives learners more time to process and therefore reduce errors of omission.

Topics: CREOG & APGO Annual Meeting, 2022, Student, Faculty, Clerkship Director, Patient Care, Medical Knowledge, Interpersonal & Communication Skills, UME, Simulation, Problem-Based Learning, Standardized Patient,

General Information

Student,Faculty,Clerkship Director,
Patient Care,Medical Knowledge,Interpersonal & Communication Skills,
Simulation,Problem-Based Learning,Standardized Patient,
Clinical Focus

Author Information

Samantha Kempner, MD, University of Michigan, Department of Obstetrics and Gynecology; Aditi Rao; Heidemann Lauren, MD; Helen K. Morgan, MD

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