CLICK BAIT: MEDICAL STUDENT DOCUMENTATION IN THE ELECTRONIC HEALTH RECORD
Jessica A Herstek,Children's National Health System,Washington,DC; Craig C. DeWolfe,Children's National Health System,,

Rationale:

Groups including the Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have published guidance emphasizing the importance of medical student participation in EHR documentation as a critical component of their educational experience and preparation for training. Much anxiety has been provoked in academic medical centers regarding compliance with federal billing guidelines and medicolegal implications, but misinformation abounds among both clinicians and adminstrators.

This workshop will review the current state of medical student documentation in the context of regulatory, medicolegal, educational objectives and provide participants the opportunity to familiarize themselves with relevant literature and comparative practices at peer institutions and across EHR vendors, in order to provide a framework to evaluate their own institutional policies and personal practices regarding medical student documentation, to encourage intellectual curiosity, professional accoutability for the accuracy and precision of documentation, and meet educational needs of future physicians while providing the highest quality and safest care to patients.



Objectives:

1. Discuss current CMS billing and documentation guidelines related to student documentation, and explore theorized and actual medicolegal liabilities, as well as sequelae and unintended consequences of learner EHR documentation on both learner and educator perceptions and experience.


2. Review current state of the industry, best practices and existing guidelines from both the graduate medical education and the clinciail ifnormatics literature on leveraging permissable EHR tools for both efficiency and educational effect, and pitfalls to patient safety, team efficiency, and learner engagement.


3. Explore alternative models from peer and participant institutions, EHR and institutional governing policies along with published models such as EHR simulation and structured documentation evaluation and feedback rubrics.


4. Formulate a plan to apply an evidence-based approach to critically appraise and reformulate as needed participants’ own institutions’ and personal practices as educators.



Methods and Content:

Workshop Timeline

Didactic Discussion: 30 minutes total

- Transition and Introductions

- Problem Statement

- Review of Advantages and Disadvantages of Electronic Documentation

- Review of Regulatory and Medicolegal Standards

Small Group Discussion: 45 minutes total

- Comparative Review of Institutional Policies and Personal Practices

- Facilitated Discussion of Alternative Models and Approaches to Student Documentation

- Introduction to Structured Evaluation and Feedback Rubrics

Group Reports and Conclusions: 45 minutes total

- Review of Literature on Best Practices and Reocmmendations

- Plan for Critical Appraisal of Institutional Policies and Personal Practices

- Questions, Further Discussion, and Follow Up Planning