Medical Student Documentation in the Medical Record: Is It a Liability?

Abstract

Medical students have routinely documented patient encounters in both inpatient and outpatient care venues. This hands-on experience has provided a way for students to reflect on patient encounters, learn proper documentation skills, and attain a sense of being actively involved in and responsible for the care of patients. Over the last several years, the practice of student note writing has come into question. Institutional disincentives to student documentation include insurance regulations that restrict student documentation from substantiating billing claims, concerns about the legal status of student notes, and implementation of electronic medical records that do not allow or restrict student access. The increased scrutiny of the medical record from pay-for-performance programs and other quality measures will likely add to the pressure to exclude students from writing notes. This trend in limiting medical student documentation may have wide-ranging consequences for student education, from delaying the learning of proper documentation skills to limiting training opportunities. This article reviews the educational value of student note writing, the factors that have made student documentation problematic, and the potential educational impact of limiting student documentation. In addition, it offers some suggestions for future research to guide policy in this area.

The Utility of EMRs in Student Run Clinics

“…Unfortunately, few medical school curricula integrate early EMR use in the pre‐clinical years. Even during the clinical years of medical education, several hospital policies limit medical students’ abilities to document information in an EMR . With limited opportunity for exposure, medical students are lacking experience and thus will be poorly equipped for navigating this ever‐increasing essential health care delivery tool.…”

Successful completion of clinical electives – Identification of significant factors of influence on self-organized learning during clinical electives with student focus groups

“…If students are given the opportunity to document their own findings and processes, i.e. are actively involved in patient treatment, this promotes further reflection and structured thinking [49]. The fact that a survey of students’ notes in 82% of cases revealed findings which had been fabricated or had been arrived at through incorrect examination techniques by students [50] underlines the desire of elective students for medical supervision and feedback on elementary clinical skills [51] to enable better SOL.…”

Perceptions of Electronic Health Records Within Otolaryngology Residents Compared to Practicing Otolaryngologists

“…Nonetheless, the role of documentation in medical education and residency training should not be underestimated as a valuable component of the curriculum. The potential consequences of limiting student documentation include the development of improper documentation skills as well as limited training opportunities . Working on finding a balance between clinical documentation skills and the development of surgical skills during residency training should be explored.…”

“…To date, there are no standard strategies provided to medical schools and hospitals training residents and employees about how to use the technology effectively while taking care of patients. However, implementation of EHR clearly requires large amounts of time and resources to be able to train residents to become proficient with the technology …”