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Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education

Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Hammoud, M. et al. Teach Learn Med 24, 257–266 (2012).

OVERVIEW

The Alliance for Clinical Education (ACE) recommends medical schools develop competencies related to student documentation in the Electronic Health Record (EHR). This article proposes introduction of the EHR should begin in the 1st year of undergraduate medical education (UME) and continue throughout the entire 4 years. Integration of EHR documentation into the UME curriculum, evaluation of competencies, and ethical, legal, and social issues around student documentation in the EHR are discussed.

PRACTICAL GUIDELINES

In the preclinical years, use of standardized patients and simulated EHR patient entries can be leveraged to teach students about EHRs. With the computer as the “third-party” in the clinical setting, role-playing, videotaping, direct preceptor observation etc. are ways in which communication can be taught in the preclinical setting. As a result of this training, in the clinical years students should be reasonably familiar with the EHR. More clinically relevant aspects of direct patient care including order entry, use of decision support, etc. could be introduced and assessed in the final year. Medical school graduates ideally should have mastered the basic approach of how EHR functions and be able to incorporate any new system into their workflow.

UME must include the ethical use of EHR, such as avoiding inappropriate use of “cut-and-paste,” and protecting confidentiality and privacy. Guidelines around student entry into the EHR must be explicit, with guidance on use of templates or prepopulated notes.

The RIME scheme is proposed as a grounding framework, however, captured in the RIME framework or not, EHR may allow evaluation of students in ACGME core competencies. Professionalism traits include honesty (not cutting and pasting) and respect for patients (HIPPA compliance). Systems-based practice can include students’ use of clinical decision aids, utilizing EHR tools to avoid errors such as medication/allergy interactions.

BOTTOM LINE

Students must: document in the patient’s chart and their notes should be reviewed for content and format; have the opportunity to practice order entry in an EHR (actual or simulated) prior to graduation; be exposed to the utilization of decision aids that typically accompany EHRs. Schools must develop a set of medical student competencies and evaluation related to EHR charting.

COMMENTARY

The article focuses almost exclusively on UME, with limited discussion of graduate or continuing medical education - however, it offers both practical and theoretical guidance for integration of EHR into the medical school curriculum. Competencies and effective ways to teach and evaluate them are delineated, offering a welcome change from missives on competencies without any practical discussion. This paper also puts forth guidelines on policy and ethics, forming a well-rounded and indispensable resource.v