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Medical students' observations, practices, and attitudes regarding electronic health record documentation
Heather L Heiman1, Sonya Rasminsky, Jennifer A Bierman
1a Department of Medicine and Augusta Webster, MD, Office of Medical Education , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA.
Teaching and Learning in Medicine
|January 11, 2014
Summary
Medical students frequently use electronic health record (EHR) efficiency tools, primarily copying their own notes. While copying from others is seen as unacceptable, students observe supervisors doing so, highlighting a gap in documentation practices.
Area of Science:
- Medical Education
- Health Informatics
- Clinical Documentation
Background:
- Medical students increasingly use electronic health records (EHRs) for patient note documentation.
- Concerns exist regarding documentation shortcuts like copy-paste and templates, potentially leading to inaccurate or redundant notes.
- Limited understanding of medical students' experiences with EHR efficiency tools.
Purpose of the Study:
- To investigate medical students' observations, practices, and attitudes towards EHR documentation efficiency tools.
- To understand the use of copy-paste, templates, and scribing among medical students.
Main Methods:
- Survey of 3rd-year medical students at a single institution.
- Inquiry into the use of copy-paste, templates, auto-inserted data, and scribing.
- Analysis of student responses regarding tool usage and attitudes.
Main Results:
- High EHR usage reported by 75% of surveyed students.
- Prevalence of observing residents (86%) and attending physicians (60%) copying notes.
- Widespread student practice of copying from own notes (95%) versus limited copying from residents (22%).
- Discrepancy in perceived acceptability: copying own notes (83%) vs. others' notes (10%).
- Association of efficiency tool use with procedural specialty interest and policy awareness.
Conclusions:
- Medical students commonly employ various EHR efficiency tools, with self-copying being most frequent.
- Students perceive copying from other providers as unacceptable but observe clinical supervisors engaging in this practice.
- Identified gap between student attitudes and observed practices of senior clinicians regarding EHR documentation.
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