Supervision: Formative Feedback for Clinical Documentation in a University Speech-Language Pathology Program

Abstract

Assessment of clinical documentation written by graduate student clinicians in the field of speech-language pathology has been viewed as a challenge for clinical instructors. Typically, instructor feedback included verbal and written comments or suggestions for modification and/or line by line edits. However, it was difficult to determine whether this feedback was useful in improving the clinical documentation skills of graduate student clinicians across semesters, given that students are rotated among clinical instructors, across disorders, and across populations. It has been well documented that verbal and written feedback to students has been inconsistent across clinical instructors (Dowling, 2001). Our University Clinic at Duquesne attempted to provide more formative and consistent feedback to students to improve clinical documentation skills. A “Grading Rubric for Clinical Documentation” developed at Duquesne's University Clinic identifies students' strengths and weaknesses in professional writing across three parameters: content, organization, and writing mechanics. Using this rubric, a “Clinical Documentation Checklist” was developed which provided a quantitative summary of performance. This checklist was given to students at various stages throughout their clinical practicum to provide quantitative information pertaining to writing skills in an effort to improve clinical documentation. In addition to this checklist, qualitative information was provided in the form of line-by-line edits and suggestions for modification of the document. Our goal was to provide both forms of information to assist students in understanding their strengths and weaknesses as they progress in their ability to document clinical encounters. This study found that most students benefitted from the verbal and written feedback provided by supervisors; however, the Documentation Checklist was also noted to be useful in improving clinical writing skills.