Medical Students' Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation

Heather L. Heiman, Sonya Rasminsky, Jennifer A. Bierman, Daniel B. Evans, Kathryn G. Kinner, Julie Stamos, Zoran Martinovich, William C. McGaghie

Research output: Contribution to journalArticle

14 Scopus citations

Abstract

Background: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy-paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students' experiences with copy-paste, templates and other "efficiency tools" in EHRs. Purposes: We sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy-paste, templates, auto-inserted data, and "scribing" (documentation under a supervisor's name). Results: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers' notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy-paste policy. Conclusions: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy-paste from other providers, most have observed clinical supervisors doing so.

Original languageEnglish (US)
Pages (from-to)49-55
Number of pages7
JournalTeaching and Learning in Medicine
Volume26
Issue number1
DOIs
StatePublished - Jan 1 2014

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Keywords

  • documentation
  • electronic health records
  • medical student education
  • professionalism

ASJC Scopus subject areas

  • Education

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