Teaching medical students the art of the ‘write‐up’

Summary Background The creation of a complete ‘write–up’ continues to be essential to the clinical learning experience for medical students. The ability to document a clinical encounter is a key communication skill and Core Entrustable Professional Activity for entering residency. Methods We developed a guide to the comprehensive write–up, a grading rubric, and a videotaped encounter with a standardised doctor and patient. Second‐year medical students created a write–up based upon this encounter, which was then peer‐reviewed in a small group writer's workshop session. The students were later required to submit a write–up, based upon a real patient encounter, to the course directors for a grade. All write–ups ( n  = 185) were graded by the course director. Fifty‐one were independently graded by a second course director. These grades were compared with the 175 student write‐ups from the previous year. The ability to document a clinical encounter is a key communication skill … for entering residencyResults The average grade for student write‐ups was 86 with a standard deviation of 9, compared with an average of 75 with a standard deviation of 17 for the year prior to the introduction of this session (p < 0.001). The average score given by a second rater was 83 with a standard deviation of 11, indicating a high level of agreement and internal consistency. Discussion These tools were easy to use and well received by faculty members and students, and the quality of student write‐ups significantly improved after the introduction of the session. The grading rubric demonstrated high inter‐rater reliability, indicating that this can be adapted and used by others for instruction and assessment.