Effect of Case-Based Learning Combined with a Workshop Teaching Model on Medical Record Writing Quality Among Residency Trainees

Summary

This study evaluates whether case-based learning, combined with a workshop-based teaching model, improves the quality of medical record writing among standardized residency trainees.

Abstract

This study evaluated the effect of a case-based learning (CBL) combined with a workshop teaching model on medical record writing quality among standardized residency trainees. This single-center, non-randomized controlled educational study included 200 standardized residency trainees, with 100 in the intervention group and 100 in the control group. The intervention group received the CBL combined with the workshop teaching model, whereas the control group received traditional lecture-based learning. Medical record writing scores were compared before and after the intervention. A linear mixed-effects model was used for the primary analysis, and analysis of covariance was performed as a sensitivity analysis. Subgroup and item-level analyses were also conducted. Baseline age, sex, specialty, training year, and pre-intervention total score were comparable between the two groups (all p > 0.05). After the intervention, total scores increased significantly in both groups, from 69.26 ± 9.66 to 85.02 ± 6.86 in the control group and from 68.92 ± 9.65 to 89.87 ± 6.44 in the intervention group (all p < 0.001). Score improvement was greater in the intervention group than in the control group (20.95 ± 6.96 vs 15.76 ± 6.19, p < 0.001). The linear mixed-effects model showed a significant time effect (β = 15.76, 95% CI 14.47–17.06, p < 0.001) and a significant group × time interaction (β = 5.19, 95% CI 3.35–7.03, p < 0.001). Sensitivity analysis yielded similar results. Greater improvements were also observed in several key items, including diagnostic and treatment planning, treatment adjustment, complication management, surgical/procedural records, informed consent forms, and discharge instructions. The CBL combined with the workshop teaching model was associated with greater improvement in medical record writing quality than traditional lecture-based learning and may represent an effective educational strategy for standardized residency training.

Introduction

Standardized residency training is an essential component of postgraduate medical education¹. The quality of such training is directly related to the development of clinical competence among residents and is also closely associated with healthcare quality and patient safety². During residency training, medical record writing serves not only as a legal documentation of clinical practice but also as an important reflection of residents’ clinical reasoning, information integration, and standardized diagnostic and therapeutic abilities³. High-quality medical records require not only completeness....

Protocol

This study was exempt from formal ethics review because it was an educational research study conducted among standardized residency trainees and did not involve patients, patient clinical data, biological samples, or any intervention affecting patient diagnosis or treatment. Before the study began, all participating trainees were fully informed of the study purpose, procedures, and intended use of the data, and written informed consent was obtained from all participants. Participation was voluntary, and trainees could withdraw at any time without affecting their training rights or benefits.

Study design and ethical considerations

Results

Baseline characteristics
A total of 200 standardized residency trainees were included in this study, with 100 in the control group and 100 in the intervention group. The mean age was (26.72 ± 3.44) years in the control group and (25.95 ± 3.23) years in the intervention group. The total medical record writing scores before the intervention were (69.26 ± 9.66) and (68.92 ± 9.65), respectively. There were no statistically significant differences between the two groups in sex, specialty, or training year.......

Discussion

Based on standardized residency trainees' medical record writing score data, this study compared the effects of the CBL combined with the workshop teaching model and the traditional LBL teaching model on the quality of medical record writing. The results showed that the total scores of both groups increased significantly after the intervention compared with before, but the magnitude of improvement was greater in the intervention group. The linear mixed-effects model showed a significant group × time interaction,.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Inpatient Medical Record Connotation Quality and Clinical Thinking Ability Evaluation Form	The Second Hospital of Hebei Medical University	Not applicable	Institutional assessment form used for evaluating inpatient medical record writing quality during standardized residency training.
Microsoft Excel	Microsoft Corporation	https://www.microsoft.com/microsoft-365/excel	Used for data entry, data management, and preparation of table files.
R software	R Foundation for Statistical Computing	RRID: SCR_001905; Version 4.3.2	Used for statistical analysis, including t tests, chi-square tests, linear mixed-effects models, and ANCOVA.
Standardized inpatient medical record template	The Second Hospital of Hebei Medical University	Not applicable	Used during Workshop-based medical record writing practice.
Teaching materials	The Second Hospital of Hebei Medical University	Not applicable	Included PowerPoint slides, teaching manuals, instructional videos, representative medical records, CBL case materials, guiding questions, Workshop exercises, and feedback documents.