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 language | English (US) |
|---|---|
| Pages (from-to) | 49-55 |
| Number of pages | 7 |
| Journal | Teaching and Learning in Medicine |
| Volume | 26 |
| Issue number | 1 |
| DOIs | |
| State | Published - Jan 1 2014 |
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Keywords
- documentation
- electronic health records
- medical student education
- professionalism
ASJC Scopus subject areas
- Education
Cite this
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Medical Students' Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation. / Heiman, Heather L.; Rasminsky, Sonya; Bierman, Jennifer A.; Evans, Daniel B.; Kinner, Kathryn G.; Stamos, Julie; Martinovich, Zoran; McGaghie, William C.
In: Teaching and Learning in Medicine, Vol. 26, No. 1, 01.01.2014, p. 49-55.Research output: Contribution to journal › Article
TY - JOUR
T1 - Medical Students' Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation
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.
PY - 2014/1/1
Y1 - 2014/1/1
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.
KW - documentation
KW - electronic health records
KW - medical student education
KW - professionalism
UR - http://www.scopus.com/inward/record.url?scp=84893147454&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84893147454&partnerID=8YFLogxK
U2 - 10.1080/10401334.2013.857337
DO - 10.1080/10401334.2013.857337
M3 - Article
C2 - 24405346
AN - SCOPUS:84893147454
VL - 26
SP - 49
EP - 55
JO - Teaching and Learning in Medicine
JF - Teaching and Learning in Medicine
SN - 1040-1334
IS - 1
ER -