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Lookup NU author(s): Dr Caroline Sprake, Dr Sarah Graham
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND).
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Background: It is common practice for senior medical students in UK General Practice to enter details of their consultations into the electronic patient record (EPR). There is evidence that students benefit educationally from writing in patient records through learning how to make good clinical entries and enhancing their clinical reasoning. In England, since 31 October 2023, patients are given full access to their EPR, including free text notes on their consultations. Despite the importance of high-quality consultation notes, guidance on writing in the patient record is rarely included in medical curricula. Approach: With patient and public involvement, the UKCCC (UK Council for Clinical Communication in Undergraduate Medical Education) developed a guide for students on writing in patients’ General Practice (GP) notes and disseminated it to all UK medical schools from August to October 2023. Results: The utility of the guide was evaluated via student and GP tutor surveys. Students and clinical teachers valued the guidance on content, structure, and clarity of consultation notes. A lack of awareness of the guide and suboptimal access and formatting on mobile devices were raised as areas for improvement. Other survey responses, which will inform the development of the next version, suggested adding links to learning resources.
Author(s): Sprake C, Schmitgen C, Brown J, Lefroy J, Graham S, Shepherd SC, Smith L, Ward A, Ward JD, Weetman K
Publication type: Article
Publication status: Published
Journal: Education for Primary Care
Year: 2024
Pages: Epub ahead of print
Online publication date: 17/12/2024
Acceptance date: 25/11/2024
Date deposited: 06/01/2025
ISSN (print): 1473-9879
ISSN (electronic): 1475-990X
Publisher: Taylor and Francis Ltd
URL: https://doi.org/10.1080/14739879.2024.2435613
DOI: 10.1080/14739879.2024.2435613
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