Taking Note of the Perceived Value and Impact of Medical Student Chart Documentation on Education and Patient Care

Friedman, Erica; Sainté, Michelle; Fallar, Robert

doi:10.1097/acm.0b013e3181eac1e0

Cited by 53 publications

(45 citation statements)

References 4 publications

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“…Our study found that the most common reason students were not allowed to document in the EHR was due to hospital/medical school institutional policies. Given that 90% of medical school deans felt students should document in the chart and 93% felt that student education would be adversely affected if this were not allowed,7 there appears to be a disconnect between educational goals and institutional policies related to documentation. It is possible that some of these policies could be due to concerns over medical liability, which emerged as another major reason for non-use even if not explicitly prohibited by hospital policy.…”

Section: Discussionmentioning

confidence: 99%

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

Wittels¹,

Wallenstein²,

Patwari³

et al. 2017

WestJEM

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IntroductionElectronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships.MethodsWe performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted.ResultsWe received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%).ConclusionClose to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for students to learn this skill.

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Section: Discussionmentioning

confidence: 99%

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

Wittels¹,

Wallenstein²,

Patwari³

et al. 2017

WestJEM

View full text Add to dashboard Cite

show abstract

“…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.…”

Section: Electronic Health Records: How Will Students Learn If They Cmentioning

confidence: 99%

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

Matson¹,

Stephens

Steiner

et al. 2014

The Annals of Family Medicine

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“…15,16 In fact, a review of articles published in Academic Medicine from 2010 to 2012 revealed 9 national survey studies on medical schools in which the response rates were as low as 51% to 64%. [17][18][19][20][21][22][23][24][25] …”

Section: Is Response Rate a Standard For Publication?mentioning

confidence: 99%

Pharmacy School Survey Standards Revisited

Mészáros

Barnett

Lenth

et al. 2013

American Journal of Pharmaceutical Education

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In a series of 3 papers on survey practices published from 2008 to 2009, the editors of the American Journal of Pharmaceutical Education presented guidelines for reporting survey research, and these criteria are reflected in the Author Instructions provided on the Journal's Web site. This paper discusses the relevance of these criteria for publication of survey research regarding pharmacy colleges and schools. In addition, observations are offered about surveying of small "universes" like that comprised of US colleges and schools of pharmacy. The reason for revisiting this issue is the authors' concern that, despite the best of intentions, overly constraining publication standards might discourage research on US colleges and schools of pharmacy at a time when the interest in the growth of colleges and schools, curricular content, clinical education, competence at graduation, and other areas is historically high. In the best traditions of academia, the authors share these observations with the community of pharmacy educators in the hope that the publication standards for survey research about US pharmacy schools will encourage investigators to collect and disseminate valuable information.

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Taking Note of the Perceived Value and Impact of Medical Student Chart Documentation on Education and Patient Care

Cited by 53 publications

References 4 publications

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

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

Pharmacy School Survey Standards Revisited

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