DEVELOPING & EVALUATING MEDICAL STUDENT NOTES IN THE ERA OF THE EHR
Gwen C. McIntosh,University of Wisconsin,Madison,WI
Rationale: Rationale: As many medical schools implement the electronic health record (EHR), it is increasingly important to train medical students in the practical clinical use of this tool. Appropriate documentation in the form of medical student notes is a crucial component of such training. Patient notes should allow medical students to communicate with the members of the health care team and to demonstrate their independent clinical reasoning. However, with the advent of the electronic health record comes access to highly detailed note templates, the ability to instantly import large amounts of data directly into the note and the risk for automatically copying elements of other providers notes. The resulting medical student note can be very challenging to assess and there is general concern that the quality of medical students notes have declined with the implementation of the EHR. Without specific effort to train medical students in EHR note writing and without repeated evaluation of these notes, medical students will not develop the skills needed to successfully and effectively document in the EHR prior to entering residency.
Objectives: 1. Identify common problems with medical student EHR notes 2. Define the ideal content for a pediatric progress note 3. Evaluate medical student EHR notes using a structured evaluation tool 4. Develop a plan for systematic evaluation of medical student EHR notes at your institution
Methods and Content: The goal of this workshop is to assist clerkship directors with developing and evaluating medical student notes in the electronic health record. Through a large group brainstorm activity we will examine both challenges and benefits to use of the EHR for medical student notes. In a small group activity followed by large group consensus building we will define the desired content and format for a pediatric electronic progress note. In a small group activity, participant will practice using a structured evaluation tool to assess sample medical student EHR notes. Lastly, each participant will work together in a small group to develop their own plan for consistent evaluation of student notes in the EHR.