Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation

Abstract

Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy-paste from other providers, most have observed clinical supervisors doing so.

Copy-and-Paste in Medical Student Notes: Extent, Temporal Trends, and Relationship to Scholastic Performance

“…Surveys suggest the use of auto-importing and copy-and-paste by medical students is essentially ubiquitous and the vast majority of students have observed supervising residents and attending physicians engaging in such practices. 6 This behavior perpetuates redundant documentation and reduces the potential for student notes to serve as educational tools, which has been a recognized goal of medical records for at least half a century. 7 Although not studied specifically in students, copy-and-paste practices have also been associated with diagnostic errors and suboptimal treatment outcomes.…”

Electronic Health Record Skills Workshop for Medical Students

“…Medical students spend a significant amount of time using the EHR during their clerkship experiences and will continue to do so as they progress to residency. 1,2 However, formal training varies between institutions and leaves gaps in data-gathering skills, 3 documentation skills, 4 and order entry. 5 We designed a workshop using a simulated EHR to teach these skills.…”

“…3 Documentation in the EHR, by students and others, is rife with copy-and-paste text, a process that decreases documentation quality and interferes with diagnostic reasoning. 4,6 Students value writing orders for their patients, but this becomes less common with the adoption of computerized physician order entry, 5 even as the Alliance for Clinical Education recommends that this activity be included in clerkship education and the Alliance for Academic Internal Medicine identifies order entry as a core entrustable professional activity for entering residency. 7,8 These gaps in EHR skills informed our workshop objectives.…”

Electronic Health Records: How Will Students Learn if They Can't Practice?

“…Surveys regarding student use of EHR 7,8 show broad institutional variation. Most differences are the result of varying local interpretations of Medicare guidelines on student EHR use.…”

“…9 The most significant barriers to medical students' access to the EHR include concerns regarding attribution of note ownership, billing elements, patient safety issues, and breaches of professionalism associated with use of the copy and paste function. 8 Increasingly, students are training in a variety of ambulatory practice settings with voluntary faculty, where the cost of additional EHR licenses for students can also be a barrier.…”