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

Authors
  • Wittels, Kathleen
  • Wallenstein, Joshua
  • Patwari, Rahul
  • Patel, Sundip
Publication Date
Dec 15, 2016
Source
eScholarship - University of California
License
Unknown
External links

Abstract

INTRODUCTION: The Association of American Medical Colleges and the Liaison Committee for Medical Education have identified documentation in the electronic health record (EHR) as a key communication skill for students to master prior to graduation. We aimed to better understand the frequency with which students in Emergency Medicine (EM) clerkships document in the EHR, faculty review of these notes, and perceived barriers to student documentation. METHODS: We conducted a cross-sectional electronic survey of EM clerkships identified through membership in the Clerkship Directors in Emergency Medicine between March and May of 2016. RESULTS: Surveys were received from 100 clerkships, representing a completion rate of 86%. 63% of institutions allow students to document in the EHR, 95% of which have a process of note-review and student feedback. The most commonly cited reasons for not allowing student documentation were medical school or hospital policy (80%) and fear of litigation (60%). Other reasons related to billing and clinical productivity, workspace limitations, educational resources and learning objectives. DISCUSSION: Student documentation in the EHR is common but far from universal in EM clerkships. Though national medical education organizations have prioritized documentation in the medical record as a key skill, institutional policies and concerns related to medical liability appear to play a significant factor in limiting more widespread use. This is despite a lack of evidence that medical student EHR documentation poses an increased medical liability risk. While there are certainly difficult barriers to overcome related to student documentation in the EHR, EM educators should investigate opportunities within their departments and advocate for students at an institutional level.

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