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Stakeholder-Informed Needs Assessment for Open Notes Curriculum in Inpatient Pediatrics
Journal article   Open access   Peer reviewed

Stakeholder-Informed Needs Assessment for Open Notes Curriculum in Inpatient Pediatrics

Nicholas C Kuzma, Angie Alegria, Stephanie Berger, Beth Harper, Andrea Ibarra Toro, Madeline Kieren, Kamakshya Patra, Cassi Smola and Michelle M Kelly
Academic pediatrics, v 26(4), Forthcoming
Mar 2026
DOI: https://doi.org/10.1016/j.acap.2026.103302
PMID: 41876044
Featured in Collection :   Research Supported by Drexel Libraries' OA Programs
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https://doi.org/10.1016/j.acap.2026.103302View
Published, Version of Record (VoR) Open Access via Drexel Libraries Read and Publish Program 2026 Open CC BY V4.0

Abstract

curriculum education inpatient pediatrics medical patient access to records qualitative research undergraduate Medical Education Pediatrics
Background and Objectives The 21st Century Cures Act mandates real-time patient access to clinical notes, introducing challenges in medical education, particularly in inpatient pediatrics where issues of confidentiality, proxy access, and sensitive topics are common. Despite this shift in practice, medical students receive little formal preparation in writing notes that patients and caregivers can read, known as Open Notes. The objective of this study was to conduct a stakeholder-informed needs assessment to inform curricula for medical student documentation in inpatient pediatrics in the Open Notes era. Methods We conducted a multi-site qualitative study using focus groups with key stakeholders involved in medical student documentation and supervision; third- and fourth-year medical students, Pediatrics residents, and pediatric hospital medicine fellows and faculty, across four U.S. academic institutions. Transcripts were analyzed using inductive thematic analysis by a research team representing multiple levels of medical training. Results Seventy-six participants across twelve focus groups identified four core content domains for Open Notes curricula: (1) adapting documentation for diverse audiences; (2) using respectful, patient-centered language; (3) documenting diagnostic uncertainty and differing perspectives among stakeholders; and (4) managing confidentiality and proxy access. Participants supported a longitudinal curriculum beginning prior to clerkships that is reinforced throughout clinical training, with low-stakes practice opportunities, structured feedback, institutional guidance, and use of electronic health record tools to support learning. Conclusions Medical students require intentional training to document effectively in the Open Notes era. This study provides a stakeholder-informed framework to guide development of undergraduate medical education curricula for inpatient pediatrics documentation.

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Collaboration types
Domestic collaboration
Web of Science research areas
Pediatrics
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