Medical Student Documentation in the Emergency Department in the Electronic Health Record Era—A National Survey

Virden, Ryan A.; Sonnett, F. Meridith; Khan, Abu N.G.A.

doi:10.1097/pec.0000000000001095

Cited by 4 publications

(6 citation statements)

References 2 publications

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“…Most of the deans indicated that limiting students’ notes would negatively affect several other issues, including preparation for internship and students’ sense of involvement . Additional barriers included concern for medical liability, an inability for student notes to support medical billing, lack of computer workspace, and inability for the clerkship to review notes …”

Section: Practical Solutions To Challengesmentioning

confidence: 99%

“…Legal liability is cited as a barrier to student note writing, although Gliatto et al . noted a paucity of information in the available literature, including no report of a medical student note being used in, or leading to, a legal case.…”

Section: Practical Solutions To Challengesmentioning

confidence: 99%

“…To facilitate feedback, a reasonable and manageable number of notes should be written during the clerkship . In one study, half or fewer of student notes were reviewed in 70% of cases, which is concerning if poor behaviors go unaddressed. Another study showed improved quality of feedback and note quality when an electronic medical record was used to as a means to evaluate notes every three to four shifts …”

Section: Practical Solutions To Challengesmentioning

confidence: 99%

“…Several barriers limit the development of documentation skills. Institutional barriers include medical legal liability and limiting student access to the EMR . Student challenges include variable instruction in navigating the EMR and lack of feedback specific to documentation .…”

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confidence: 99%

“…Institutional barriers include medical legal liability and limiting student access to the EMR . Student challenges include variable instruction in navigating the EMR and lack of feedback specific to documentation . Preceptors have limited time to review lengthy student notes and may not fully understand the expectations for student documentation to give effective feedback …”

mentioning

confidence: 99%

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Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department

Olaf

2019

AEM Education and Training

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Documentation is part of a critical foundation of skills in the undergraduate medical education curriculum. New compliance rules from the Centers for Medicare and Medicaid Services will impact student documentation practices. Common barriers to student documentation include limited access to the electronic medical record, variable clerkship documentation expectations, variable advice regarding utilizing the electronic medical record, and limited time for feedback delivery. Potential solutions to these barriers are suggested to foster documentation skill development. Recommendations are also given to mitigate compliance and legal risk.

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Section: Practical Solutions To Challengesmentioning

confidence: 99%

Section: Practical Solutions To Challengesmentioning

confidence: 99%

Section: Practical Solutions To Challengesmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department

Olaf

2019

AEM Education and Training

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Documentation from trained medical students has a low rate of relative downcoding for emergency medicine encounters

Tillman

Jewell

Hekman

et al. 2022

AEM Education and Training

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Background Since 2018, the Centers for Medicare & Medicaid Services (CMS) guidelines have allowed teaching physicians to bill for evaluation and management services based on medical student documentation. Limited previous data suggest that medical student documentation suffers from a high rate of downcoding relative to faculty documentation. We sought to compare the coding outcomes of documentation performed by medical students, and not edited by faculty, with documentation edited and submitted by faculty. Methods A total of 104 randomly selected notes from real patient encounters written by senior medical students were compared to the revised notes submitted by faculty. The note pairs were then split and reviewed by blinded professional coders and assigned level of service (LoS) codes 1–5 (corresponding to E&M CPT codes 99281–99285). Results We found that the LoS agreement between student and faculty note versions was 63%, with 23% of all student notes receiving lower LoS compared to faculty notes (downcoded). This was found to be similar to baseline variability in professional coder LoS designations. Conclusions Notes from medical students who have completed a focused documentation curriculum have less LoS downcoding than in previous reports.

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Self-Perceptions of Readiness to Use Electronic Health Records Among Medical Students: Survey Study

Lander¹,

Baxter²,

Cochran³

et al. 2020

JMIR Med Educ

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Background Although several national organizations have declared the ability to work with electronic health records (EHRs) as a core competency of medical education, EHR education and use among medical students vary widely. Previous studies have reported EHR tasks performed by medical students, but students’ self-perceived readiness and comfort with EHRs are relatively unknown. Objective This study aimed to better understand medical students’ self-perceived readiness to use EHRs to identify potential curricular gaps and inform future training efforts based on students’ perspectives. Methods The authors deployed a survey investigating self-perceived comfort with EHRs at 2 institutions in the United States in May 2019. Descriptive statistics were generated regarding demographics, comfort level with various EHR-related tasks, and cross-institutional comparisons. We also assessed the impact of extracurricular EHR experience on comfort level. Results In total, 147 medical students responded, of which 80 (54.4%) were female, with equal distribution across all 4 years of training. Overall confidence was generally higher for students with longer extracurricular EHR experience, even when adjusted for age, gender, year of training, and institution. Students were most comfortable with tasks related to looking up information in the EHR and felt less comfortable with tasks related to entering new information and managing medications. Fourth-year students at both schools reported similar levels of comfort with EHR use, despite differences in preclinical EHR training. Open-ended comments emphasized the value of experiential training over didactic formats. Conclusions Information entry and medication management in the EHR represent areas for future curricular development. Experiential training via extracurricular activities and early clinical exposure may be high-yield approaches to help medical students achieve critical EHR competencies.

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Medical Student Documentation in the Emergency Department in the Electronic Health Record Era—A National Survey

Abstract: This study presents data describing the current practice of medical student documentation in academic pediatric EDs in the United States. There is a strong consensus among educators and students on the usefulness of medical student documenting patient encounters in the ED.

Cited by 4 publications

References 2 publications

Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department

Pupil Prose Appraisal: Four Practical Solutions to Medical Student Documentation and Feedback in the Emergency Department

Documentation from trained medical students has a low rate of relative downcoding for emergency medicine encounters

Self-Perceptions of Readiness to Use Electronic Health Records Among Medical Students: Survey Study

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