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Electronic Health Record Skills Workshop for Medical Students
Jillian Zavodnick1, Tasha Kouvatsos1
1Clinical Assistant Professor, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University.
Introduction:
The adoption of electronic health records (EHRs) presents new challenges for information gathering, documentation, and patient care. 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. However, formal training varies between institutions and leaves gaps in data-gathering skills, documentation skills, and order entry-these three skills formed the basis for our learning objectives. We designed a workshop using a simulated EHR to teach these skills.
Methods:
We offered the workshop during a class-wide transition-to-internship course for senior medical students. After a brief didactic, students worked in small groups using a simulated EHR to complete cases addressing each of the three learning objectives. Faculty facilitators assisted groups and then guided a large-group discussion of the challenges encountered during the cases.
Results:
Twenty-five senior medical students attended the first optional workshop. Of these students, 66.7% recommended that the workshop continue to be included in the curriculum. Comments from those who recommended otherwise suggested that many of them would recommend the workshop if it used our local EHR (Epic). Correct answers to the factual questions increased for most questions between the pretest and the posttest. Confidence to perform all skills targeted in the learning objectives increased between the pretest and the posttest.
Discussion:
This EHR workshop was well received by senior medical students and increased confidence in EHR skills, including data gathering, documentation, and handling unsolicited information with a plan including order entry.
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Related Concept Videos
Methods of Documentation VII: EMR
Purpose of Health Records II
Types of Records II: Educational and Administrative Records
Methods of Documentation II: POMR
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes: