Council on Medical Student Education in Pediatrics

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COMSEP 2012 Indianapolis Meeting

Poster Presentation:


Maintaining Medical Student Documentation Skills Using the Simulated Medical Record

Authors:
Mitzi S Scotten, M.D. - University of Kansas Medical Center, Kansas City

Background:The ability of physicians to write skillful and complete medical orders remains a cornerstone of safe and effective medical care. Competency in this domain is gained through the early introduction, assessment and use of order writing skills by medical students during their training. Current trends in the widespread use of the electronic medical record at many University hospitals may jeopardize the training of medical students if they are not allowed to participate in order writing under the new computer systems.

Aims:Students will be re-introduced to the skills required to write complete admission orders on pediatric patients using simulated medical records.

At completion of the six week Pediatric clerkship, third year students will be expected to improve their ability to write admission orders using the simulated electronic record.

Methods:  During orientation,students are asked to review one of five simulated pediatric patient scenarios and write a set of admission orders based on the medical information given in the profile.  Immediately following, there is a didactic session reviewing pediatric order writing and major patient safety issues. Students receive feedback and a copy of their initial order sets during their mid-clerkship meeting with the course director.

Students are asked to write a second set of admission orders at the completion of their clerkship using a different simulated patient.

Measurement of the educational intervention is assessed by comparing students’ improvement from their first attempt to the second.

 Scoring of the exercise consists of a checklist that includes the major criteria needed for a complete set of standard admission orders. Students are asked to participate in a post-interventional questionnaire to assess effectiveness of the lecture and overall experience.

Results: To date, four of the eight clerkships have participated in the exercise. A complete data set is not available at the time of this abstract, but early trends suggest that students show statistical improvement in order writing skills after this intervention.