Council on Medical Student Education in Pediatrics


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COMSEP Meeting in Ottawa, ON

Poster Presentation:

Medical Student Documentation in the Electronic Healthcare Record and Implementation of a Self-assessment Tool

Edith P. Allen,Phoenix Children's Hospital,Phoenix,AZ

The aim of this study is to assess the 4th year medical student’s (MS-4) ability to auto-evaluate their electronic healthcare record (EHR) documentation.

This is a descriptive retrospective study, included MS-4 that completed their pediatric inpatient sub-internship (sub-I) from July to December 2013. We created a self-assessment form listing 9 items with expected skills and common pitfalls in EHR physician’s documentation. The MS-4 was required to submit an EHR note once a week during their 4 week elective. Along with the EHR note, the student was also required to complete a self-assessment form. The student was instructed to compare their EHR document with the one generated by licensed physicians (subspecialist and/or resident/attending) and grade himself. The Elective Director (ED), independently reviewed the student’s and the licensed physician’s notes and also completed a self-assessment form grading the students’ performance. The student’s second week documentation was chosen for the project (one document set per student). The grades from both (MS-4 and elective director) were compared. Data analysis plan: A cumulative logistic model was used to determine the odds ratio for which group S (student) or A (attending) tended to score a question higher. McNemar’s test for paired proportions was used to compare the discordant pairs for each subject.

A total of 31 MS-4 were included in the project, there was no statistical significant difference on how the ED and MS-4 graded their EHR, except for item #2 (Did your note look like a “cut and paste”?) and item # 8 (Did you document education provided to the patient or their family?) (OR 9.8 and 2.6; p-value 0.03 and 0.04 respectively).

We concluded that a MS-4 can do a very good job on self-assessing their EHR documents.

Although the size of our study is small, this is an initial step to attempt to introduce proper use of the EHR to the curriculum of the MS-4 and easily can be adapted for the 3rd year medical students.