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

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14 Citations (Scopus)

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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Electronic Health Records
Ointments
Medical Students
Documentation
documentation
medical student
electronics
Students
efficiency
health
Medical Schools
student
Names
resident
school
physician
educator
Physicians
lack
experience

Keywords

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

ASJC Scopus subject areas

  • Education

Cite this

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title = "Medical Students' Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation",
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.",
keywords = "documentation, electronic health records, medical student education, professionalism",
author = "Heiman, {Heather L.} and Sonya Rasminsky and Bierman, {Jennifer A.} and Evans, {Daniel B.} and Kinner, {Kathryn G.} and Julie Stamos and Zoran Martinovich and McGaghie, {William C.}",
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AU - Heiman, Heather L.

AU - Rasminsky, Sonya

AU - Bierman, Jennifer A.

AU - Evans, Daniel B.

AU - Kinner, Kathryn G.

AU - Stamos, Julie

AU - Martinovich, Zoran

AU - McGaghie, William C.

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N2 - 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.

AB - 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.

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