To resolve a deficit in learning outcomes specific to clinical documentation.
Data from the Clinical Performance Instrument (CPI)1 revealed a deficit in documentation of learning objectives for the students involved in clinical education courses. The data included CPI scores, comments from the clinical instructors and the students’ self-assessments. A plan was established to correct this deficit. The plan included: 1) establish a committee to focus on the documentation learning objectives in the clinical education courses; 2) examine courses in the entire curriculum to identify documentation methods; 3) identify courses where documentation was deficient; 4) devise recommendations to improve the methods used for teaching documentation; and, 5) evaluate the outcome of these changes as evident in the assessment data from the clinical education courses.
The committee was comprised of the Director of Clinical Education and four academic faculty educators teaching clinical courses. The committee was charged to review the curriculum specific to documentation and present recommendations based on the findings. The committee recommended an increase in the rigor of documentation taught in each clinical course within the curriculum. The specific recommendations included: The utilization of specific case scenarios which the student would effectively document patient history, examination, assessment, planning and treatment.2 In addition, the students must establish a plan of care to include patient goals that are culturally competent, specific, measurable, attainable, result-oriented and time-specific.3 The curricular intervention occurred during the fall semester of 2008. Continued assessment of clinical education revealed the curricular changes resulted in a positive outcome.
In 2009 – 2010 assessment data revealed CPI scores in the area of documentation improved and, while some clinical faculty viewed documentation as an area of student weakness, others viewed it as an area of strength. Students did not cite documentation as an area of weakness. In 2011 – 2012, CPI data revealed continued improvement in a positive direction and clinical faculty now cited documentation as a student strength. Data collected in 2013 continued to demonstrate that the learning deficit is corrected and documentation remains a student strength, as noted by clinical faculty. Student self-assessment revealed confidence in documentation. For the 2014 calendar year, 73% of the students, as noted in the CPI, scored documentation as a strength. Only 2% of the students scored documentation as a weakness.
Conclusions/Relevance to the conference theme: Shaping the Future of Physical Therapy Education
Following the implementation of our plan, the assessment data revealed that the area of documentation as now viewed by clinical faculty, is a student strength rather than a deficit.
1. American Physical Therapy Association, Physical Therapist Clinical Performance Instrument. 2006 June
2. American Physical Therapy Association. Guidelines: Physical Therapy
Documentation of Patient/Client Management BOD G03-05-16-41.
3. Kolber M, Lucado A, Risk Managment Strategies in Physical Therapy: Documentation to Avoid Malpratice. International Journal of Healthcare Quality