Do you have medical students rotating in your Emergency Department? Are they allowed to document in the medical record?
Charting in the medical record is the cornerstone of clinical communication. You document your findings, your clinical reasoning, and management plan. The medical record allows communication amongst providers. Chart documentation is a crucial skill that every medical student should know, as stated by the Association of American Medical Colleges (AAMC).
However, there is a growing trend whereby medical students are no longer being allowed to document in the medical record. I find this alarming, because this was often how I assessed their knowledge and clinical competency. Various reasons for excluding students include:
- Medicolegal risk
- Inaccurate information
- Unsigned notes
- Inability to bill and be reimbursed
This is especially true for institutions where the medical record is electronic and not paper-based. These electronic medical records (EMR) tend to lock-out and restrict access by students.
This Academic Medicine study reports results from a 23-item survey of medical school deans in the U.S. and Canada. The response rate was 63% (79/126). - 96% and 94% of respondents stated that 4th-year student notes should be included in the inpatient and outpatient records, respectively.
- Not feeling a part of the team (96%)
- Inadequate preparation for internship (95%)
- Lack of a sense of being involved (94%)
Bottom line - Getting to the point:
Medical school deans overwhelmingly support that medical students' notes be included as part of the patient's official medical chart from an educational standpoint. Furthermore, it promotes a sense of inclusion on the medical team.
The authors advocate that governing organizations such as AAMC, the Liaison Committee for Medical Education (LCME), or the Alliance of Clinical Educators (ACE) should officially recommend that student notes be included in the patient chart.
I totally agree. It isn't like entering PGY-1 residents can magically document better now that they have just graduated from medical school. Medical students should be taught how to and be allowed to document in the chart, with appropriate guidance. The starting PGY-1 residents are already stressed out in adapting to a new system with new responsibilities. There's no need to add chart documentation to their list of things to learn!
Reference
Friedman E, Sainte M, & Fallar R (2010). Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Academic medicine : journal of the Association of American Medical Colleges, 85 (9), 1440-4 PMID: 20736671
One of the few good things to come out of the Bali Bombing Response in Darwin Australia , was the use of medical students as "scribes". Each severely injured person , or group , had a student assigned to write a linear account of the events . Often as direct dictation or as a description of events/procedures. The result was a real time record, written by people familiar with the jargon: And in most cases their writing was clearer than the hasty scribble between crises that was the alternative.
ReplyDeletePeter Harbison
I am on my third consecutive EM rotation at three different hospitals and none have allowed us to document in the chart. Its my sense that its not that faculty doesn't WANT us to chart, but rather that the logistics on getting us trained on their particular computer software, getting appropriate log in information is more hassle than its worth given its only a 4 week rotation.
ReplyDeleteHey James: Wow, 3 consecutive EM rotations! I thought I was the only one crazy enough to do that during med school. I agree- the faculty actually do want students to document across the board. But I also think that it's worth the logistics of training/enabling computers to allow student documentation. I think students miss out on intangible learning value from documenting in the chart.
ReplyDeletePeter: How interesting! Our ED is entertaining the idea of "scribes" to help with implementing our upcoming EMR. These will be medical students/college students specifically trained in documentation.
ReplyDeleteWith students no longer being allowed to write in the chart in my ED, the responsibility now falls on the rushed attending to document everything. Before we implemented the no-documentation rule for students, I found that student notes were actually more complete and legible than attendings!
I've been fortunate that at my medicine rotation as an MS3 I've written the notes on my patients, and then daily sat down with the attending and gone over the note, and then the attending signs it as their own. I learned as much from those times as almost any other. Maybe not possible in the ED, but definitely possible on other rotations.
ReplyDeleteHi KH: That's good to hear. In this study that I referenced, it turns out that hospitals with paper charts definitely allowed students to add their notes in the chart compared to EMRs. That's fantastic that you had an attending to spend time going over the note. That'll be really important to take with you as you get into residency and beyond.
ReplyDeleteI think using medical students or premed students as scribes are a good idea for workflow issues and productivity for physicians. It does provide some education from a charting methodology, vocabulary, and work up for the scribes. But it does not replace the students creating a chart entry for their own patients and is not a replacement for this.
ReplyDeleteAt EDs that use the T Sheet it is difficult to have multiple T Sheets, ie. one from the medical student and one from the resident or attending. I think this causes some problems for the education on charting. One compromise is to have the medical student fill out a T Sheet that is evaluated but not included in the chart due to billing and coding issues.
Great thoughts by everyone.
ReplyDeleteOur ED has a scribe program which has increased productivity and billing. We typically try to recruit folks who are pre-med, pre-nursing, pre-PA, etc. We also use our providers as scribes while they are waiting for their hospital privileges. This allows them to learn the EMR and overall flow of the department. I think there was a recent paper on scribes (maybe in Academic Emergency Medicine?).
I also agree that students should be allowed to document. How else are they going to learn this vital skill. In our ED, all students go through computer orientation and document in the EMR. Our providers will first click into the chart so it is their patient but the student is allowed to chart. I also add a note that says "I have reviewed the above charting by the student and agree with their findings. I also examined the patient.".
At a previous ED where we did not have EMR, I would photocopy a blank chart for the student to practice charting (and review their charting).
Jason and Fred: That is great that you are familiar with scribes. Sounds like we're about to implement at my site as well. Having a "ghost" chart for the student to write on is only useful if there's someone to actually go over the note. If included in the actual chart, I'm guessing the senior resident or attending will go over it more carefully, as KH mentions.
ReplyDeletethank you
ReplyDelete