Medical Student Documentation in Electronic Health Records: A Collaborative Statement From the Alliance for Clinical Education

被引:75
作者
Hammoud, Maya M. [1 ]
Dalymple, John L. [2 ]
Christner, Jennifer G. [1 ]
Stewart, Robyn A. [3 ]
Fisher, Jonathan [4 ]
Margo, Katherine [5 ]
Ali, Imran I. [6 ]
Briscoe, Gregory W. [7 ]
Pangaro, Louis N. [8 ]
机构
[1] Univ Michigan, Sch Med, Ann Arbor, MI USA
[2] Univ Texas Med Sch, Houston, TX USA
[3] Cleveland Clin, Breast Serv, Lerner Sch Med, Cleveland, OH 44106 USA
[4] Beth Israel Deaconess Med Ctr, Boston, MA 02215 USA
[5] Univ Penn, Sch Med, Philadelphia, PA 19104 USA
[6] Univ Toledo, Coll Med, Toledo, OH 43606 USA
[7] Eastern Virginal Med Sch, Norfolk, VA USA
[8] Uniformed Serv Univ Hlth Sci, Dept Med, Bethesda, MD 20814 USA
关键词
INFORMATION TECHNOLOGIES; IMPACT; CHART;
D O I
10.1080/10401334.2012.692284
中图分类号
G40 [教育学];
学科分类号
040101 ; 120403 ;
摘要
Purpose: The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care, but it creates special challenges for student education. This article represents a collaborative effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in 1992. ACE recognizes the importance of medical student participation in patient care including the ability of documentation. This article proposes guidelines that can be used by educators to establish expectations on medical student documentation in EHRs. Summary: To provide the best education for medical students in the electronic era, ACE proposes to use the following as practice guidelines for medical student documentation in the EHR: (a) Students must document in the patient's chart and their notes should be reviewed for content and format, (b) students must have the opportunity to practice order entry in an EHR-in actual or simulated patient cases-prior to graduation, (c) students should be exposed to the utilization of the decision aids that typically accompany EHRs, and (d) schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation. In addition, ACE recommends that accreditation bodies such as the Liaison Committee for Medical Education utilize stronger language in their educational directives standards to ensure compliance with educational principles. This will guarantee that the necessary training and resources are available to ensure that medical students have the fundamental skills for lifelong clinical practice. Conclusions: ACE recommends that medical schools develop a clear set of competencies related to student documentation in the EHR which medical students must achieve prior to graduation in order to ensure they are ready for clinical practice.
引用
收藏
页码:257 / 266
页数:10
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