Peijia Yu, Jing Zhao, Jing Zhang
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.