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.
N1 - Funding Information:
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was supported by an Augusta Webster, MD Grant for Educational Innovation at the Feinberg School of Medicine, Northwestern University. Dr. McGaghie’s contribution was supported in part by the Jacob R. Suker, MD, Professorship in Medical Education at Northwestern University and by grant UL 1 RR025741 from the National Center for Research Resources, National Institutes of Health. The National Institutes of Health had no role in the preparation, review, or approval of the manuscript.
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
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U2 - 10.1080/10401334.2013.857337
DO - 10.1080/10401334.2013.857337
M3 - Article
C2 - 24405346
AN - SCOPUS:84893147454
SN - 1040-1334
VL - 26
SP - 49
EP - 55
JO - Teaching and Learning in Medicine
JF - Teaching and Learning in Medicine
IS - 1
ER -