Bridging Theory and Practice: a qualitative study on electronic charting and health systems science in Korean medicine education in alignment with KAS2022

Abstract

Objectives

The digital transition in healthcare has underscored the importance of charting competence. However, medical record education remains fragmented and insufficient. With the introduction of competency-based assessments in KAS2022, there is an urgent need for structured training that integrates paper and electronic charts in Korean medicine education.

Methods

This qualitative study conducted focus group interviews with 19 students from a Korean medicine university. Participants were tasked with documenting standardized cases using both a paper chart and an electronic chart (Doodol-Chart). They then engaged in group interviews according to academic year to explore their experiences, challenges, and perceptions.

Results

Students primarily learned charting through informal channels, leading to difficulties in structured history-taking and the use of professional terminology. Paper charts were valued for their flexibility but hindered systematic record management. Conversely, electronic charts facilitated faster data entry and organized storage but limited free-text flexibility. Students emphasized the need for early foundational training, a standardized curriculum, and clinically integrated practice. Electronic chart education was also noted to reinforce Health Systems Science (HSS). Despite the benefits of electronic charting, our focus group interviews revealed challenges related to informal training and restricted flexibility, underscoring the complementary insights of qualitative inquiry.

Conclusion

Structured charting education is essential in Korean medicine. Integrating electronic charting within the HSS framework underscores the need for comprehensive strategies that enhance clinical reasoning and collaboration. Specifically, developing electronic medical record-integrated assessment tools is crucial for bridging the gap between theory and practice, ensuring the professional identity and sustainability of future Korean medicine practitioners.

INTRODUCTION

The accelerating digital transition in healthcare has made competence in medical record documentation increasingly vital in clinical practice. In response, several countries have integrated electronic chart education into their medical curricula. A 2024 study reported that in both the United States and Europe, practical training methods such as, recording real patient data using electronic charts, receiving feedback, and peer-based comparisons, are increasingly implemented alongside traditional paper charting. Notably, a recent educational model demonstrated its effectiveness by providing pediatric residents with quantitative feedback on diagnostic scope and exposure through electronic chart data [1]. These findings suggest that electronic chart training should move beyond simple technical instruction to adopt a multifaceted ‘blended approach’ that integrates e-learning, simulation, and peer coaching to ensure sustainable clinical competence. Similarly, this approach has been emphasized in nursing education, where studies have demonstrated that combining diverse educational modalities (e.g., e-learning, simulation, and peer mentoring/coaching) is more effective than relying solely on traditional lecture-based instruction [2].

Despite these advancements, both domestic and international studies indicate limitations in medical record education. In Korea, medical record training is often covered only sporadically within clinical clerkships or certain courses, rather than being offered as an independent subject [3]. Consequently, deficiencies in essential documentation skills, proficiency with electronic chart systems, and accuracy in medical record writing remain prevalent. This highlights a continued need for stronger and more standardized training in this area. Similar challenges have been observed internationally, with interviews of medical students and residents revealing significant variation and deficiencies in charting competence, largely due to the lack of systematic training [4]. Therefore, both domestically and internationally, concerns persist that current training in electronic medical record management lacks systematization, clinical applicability, and learner-centered experiential engagement. Accordingly, there is a growing call to incorporate record-keeping education into the formal curriculum and clinical clerkships, as well as to innovate toward practice-based, participatory teaching methods. Given the shortcomings of current medical record education, there is an urgent need to establish structured training and assessment methods that can be effectively applied in actual clinical settings.

In addition, charting and clinical procedural skills are recognized as core competencies in Korean medicine education. The recently revised Korean Medicine Education Accreditation Standards 2022 (KAS2022) has restructured the curriculum to focus on competency-based education, mandating the use of OSCE (Objective Structured Clinical Examination) and CPX (Clinical Performance Examination) as essential assessment tools. Specifically, KAS2022 requires that OSCE and CPX be implemented within the past two years to objectively evaluate students’ clinical competence in providing primary care upon graduation [5]. These institutional mandates imply that clinical procedural skills cannot be decoupled from medical documentation; rather, they must be assessed as part of an integrated continuum of clinical reasoning and systematic record management. As such, the effective implementation of OSCE and CPX requires concurrent training and research on charting competence. For OSCE and CPX to function as core elements of competency-based education, students must receive integrated training that spans history-taking, diagnosis, and documentation. This underscores the increasing importance of research and education in medical charting.

A study by Lee et al. [6] demonstrated that learning efficiency was significantly improved by electronic chart education compared to paper chart training among Korean medical students. However, the study did not explore the psychological and experiential factors underlying the findings. To address this gap, the present study employs a qualitative research method to explore students’ perceptions, difficulties, and educational needs—elements that quantitative data alone cannot fully capture. Qualitative research allows for a deeper examination of phenomena from the perspective of participants, providing new insights that integrate both researchers’ and participants’ viewpoints [7].

In this context, the present study aimed to assess the current state of charting education at a Korean medicine college. Specifically, students at Dong-Eui University College of Korean Medicine were asked to document standardized clinical cases using both paper and electronic charts, followed by focus group interviews. This design sought to explore the challenges students encounter in history-taking and documentation, while comparing the advantages and disadvantages of paper and electronic charts. Ultimately, the findings could offer practical implications for developing effective educational strategies to enhance medical record documentation competence in Korean medicine education.

MATERIALS AND METHODS

1. Participants

In May 2025, a total of 19 students enrolled at Dong-Eui University College of Korean Medicine were recruited through purposive sampling. Participants were intentionally selected to represent varying academic years and levels of exposure to charting. Specifically, students were categorized into three groups based on the grade system outlined by the Korean Institute of Korean Medicine Education and Evaluation: P1 (second-year premedical students), P2 (first- and second-year students in the main Korean medicine curriculum), and P3 (third- and fourth-year students in the main curriculum). After explaining the purpose and significance of the study and obtaining voluntary consent, participants were grouped according to their academic year and prior charting experience (Table 1).

Table 1.

Participant characteristics

Group	Participants (n)	Grade
Phase 1	6	Pre-medical course in Korean Medicine 2nd grade
Phase 2	6	College of Korean Medicine 1st and 2nd grade
Phase 3	7	College of Korean Medicine 3rd and 4th grade

Premedical first-year students were intentionally excluded because they had no formal education or practical exposure to charting or electronic chart systems, which limited their ability to provide information-rich reflections relevant to the study aims. Therefore, only premedical second-year students were included in the P1 group.

2. Study design

This study employed a qualitative research approach utilizing focus group interviews to conduct an in-depth analysis of Korean medicine students’ experiences and perceptions regarding medical record documentation. Participants were divided into groups based on their academic year. After documenting clinical cases using both paper and electronic charts, they participated in group interviews. Although the interviews were conducted on separate dates for each group, the procedure was identical.

The research team included members who were students at the same institution as the participants, with prior experience in electronic chart systems. This positionality provided contextual understanding of the educational environment but also introduced potential interpretive bias. To mitigate this, the researchers adopted a reflexive approach throughout the data collection and analysis process, ensuring that personal experiences or expectations did not unduly influence interpretations. In addition, a semi-structured interview guide was employed, and multiple researchers engaged in iterative discussions during the coding and theme development stages. Differences in interpretation were resolved through consensus, and all analytic decisions were grounded in participants’ verbatim statements.

1) Chart documentation

Before the interviews, each participant was tasked with documenting cases using both paper and electronic charts. Standardized clinical cases were generated using a generative AI tool, with cases adapted from textbooks commonly used in clinical classes. The case for paper charting was based on asthma, and the case for electronic charting (Doodol-Chart) was based on tuberculosis.

2) Focus group interviews

Following chart documentation, focus group interviews were conducted with each group. The interviews centered on key guiding questions and encouraged open discussion among participants. Focus group interviews were held in a quiet seminar room at the university to ensure a comfortable and non-disruptive environment. Participants were grouped by academic year to facilitate peer discussions and minimize power dynamics. Only participants and researchers were present during the interviews, and all sessions were audio-recorded with the participants’ consent. Each interview lasted approximately 60–90 minutes and adhered to a semi-structured interview protocol.

3) Data analysis

Qualitative data were analyzed using an inductive thematic analysis approach. Audio recordings of the focus group interviews were transcribed verbatim, and two primary researchers independently reviewed the transcripts to generate initial codes, which were based on meaningful units within participants’ statements. These codes were derived inductively from the data rather than from a predetermined framework. The researchers then compared and discussed the generated codes, refining code definitions and grouping related codes into broader themes. Discrepancies in coding or interpretation were resolved through consensus. The preliminary themes were reviewed and agreed upon by all members of the research team to enhance analytic rigor and credibility.

Although formal methodological triangulation or member checking was not implemented due to practical constraints, analytic credibility was enhanced through investigator triangulation. Multiple researchers independently conducted coding and engaged in iterative discussions to achieve consensus. Data saturation was assessed during the concurrent process of data collection and analysis. After each focus group interview, the transcripts were repeatedly reviewed and coded. Data saturation was determined to have been reached when subsequent interviews no longer generated new themes or conceptual categories, and participants’ responses consistently reflected previously identified patterns. At this point, additional data collection was deemed unlikely to yield new insights, and recruitment was concluded with a total of 19 participants.

3. Interview questions

The interview questions were designed to explore participants’ experiences with charting, the difficulties they encountered, their educational needs, and their perceptions of the differences between paper and electronic charts (Table 2).

Table 2.

Interview guide on charting education and practice

Charting education experience

1. Have you ever received formal training in charting?

2. (If yes) Where and from whom did you receive it, and what content was mainly covered?

3. What was the most helpful content?

Practical experience in charting

1. Apart from this study, have you ever written medical charts before?

2. (If yes) When did you first write a chart, and did you use a paper chart or an electronic chart?

Difficulties in charting

1. What was the most difficult aspect of charting, and why do you think it was difficult?

Educational needs

1. What kind of training do you hope to receive to overcome the difficulties in charting?

2. Why do you think such training is necessary?

Preference for chart type

1. Which do you find more convenient, paper charts or electronic charts, and why?

RESULTS

1. Results of focus group interviews

1) Experiences in charting education and identified issues

Participants reported that their primary exposure to history-taking and charting methods occurred through clinical volunteer activities or guidance from senior peers in academic clubs. The training they received mainly focused on question-asking techniques and the explanation of charting terminology, which participants found helpful in avoiding vague inquiries and in learning how to ask specific and detailed questions.

However, several issues with the current charting education were identified. Many students noted that they learned charting informally through clinics or senior peers rather than through formal instruction, which often resulted in an insufficient understanding of basic principles such as the SOAP (Subjective, Objective, Assessment, Plan) method. In addition, participants reported that the lack of integration with clinical practice made it difficult for them to connect patient symptoms to diagnostic conclusions.

2) General difficulties in charting and perceived strengths and weaknesses of each chart type

The greatest difficulty participants encountered in charting was organizing questions in a systematic and efficient manner. This challenge stemmed from inexperience in selecting relevant diagnostic information and conducting history-taking in a logical sequence, rather than simply transcribing patients’ words. Furthermore, participants reported challenges with the use of professional terminology (abbreviations and Chinese characters) in both paper and electronic charts, as well as difficulties in differentiating diseases, which affected their diagnostic accuracy.

Participants also demonstrated a clear understanding of the strengths and weaknesses of paper and electronic charts. These findings are summarized in Table 3.

Table 3.

Advantages and disadvantages of electronic charts and paper-based records

	Advantages	Disadvantages
Electronic charts	Time efficiency, readability, ease of questioning, information retrieval, clinical relevance, information storage	Lack of familiarity with abbreviations, reduced readability, limited flexibility, lack of rapport
Paper-based records	High flexibility, patient-centeredness	Unfamiliar format, terminology difficulty, inefficiency

Electronic charts were perceived as advantageous in several ways. They were noted to improve time efficiency through rapid typing and clicking, as well as to enhance readability by incorporating Korean-based clinical terminology. Students also highlighted the ease of questioning, as the compartmentalized user interface (UI) facilitated rapid identification of subsequent questions during history-taking. In addition, electronic charts allowed for better information retrieval, particularly for returning patients, and contributed to greater clinical relevance by reflecting actual clinical settings through the inclusion of diagnostic codes. The ability to systematically store large volumes of data was also identified as a key strength of electronic charts.

However, students also pointed out several limitations of electronic charting. A lack of familiarity with clinical abbreviations was frequently mentioned, and readability was reduced in cases where chief complaints were entered as lengthy text. Participants also noted limited flexibility due to predefined input fields, which could result in the omission of essential information, and described a lack of rapport with patients when attention was diverted to the screen. Additional challenges included difficulty in adapting to unfamiliar charting formats and terminology, particularly when interpreting Chinese characters. Furthermore, inefficiencies inherent in traditional documentation practices, such as illegible handwriting and challenges with record storage and retrieval, were highlighted.

In contrast, paper charts were valued for their high degree of flexibility, allowing students to link information freely and use drawings and symbols for documentation. They were also regarded as more patient-centered, as they allowed the verbatim recording of patients’ own words during history-taking. However, several limitations of paper-based records were identified. Students reported the difficulty of adapting to unfamiliar charting formats, as well as issues with terminology, particularly regarding Chinese characters. In addition, inefficiencies were highlighted, such as the potential for illegible handwriting and challenges with record storage and retrieval (Table 3).

3) Educational needs in charting

Students emphasized the importance of foundational training in charting skills and questioning techniques starting from the early years of their education. They expressed a desire for more opportunities to engage in and practice actual charting, and in later years, they wished to learn differential approaches for diagnosing diseases and symptoms specific to each specialty. In addition, they highlighted the need for guidelines on essential questions to ask during patient history-taking and called for the establishment of a standardized charting education system across Korean medicine colleges.

2. Health systems science (HSS) analytical framework

HSS is defined as the principles, methods, and practices necessary to improve the quality of healthcare delivery, patient experiences, health outcomes, and costs. It is often described as the ‘third pillar’ of medical education, complementing the traditional pillars of basic science and clinical medicine.

HSS consists of seven core domains, four foundational domains, and one bridging domain. The core domains include: (1) patients, family, and community; (2) healthcare structure and process; (3) healthcare policy and economics; (4) clinical information and health technology; (5) population, public, and social determinants of health; (6) value in healthcare; and (7) health system improvement. The foundational domains are: (1) change agency, management, and advocacy; (2) ethics and legal; (3) leadership; and (4) teamwork. The bridging domain, which integrates the core and foundational domains, is systems thinking (Fig. 1) [8, 9].

Figure 1.

The conceptual framework of Health Systems Science [9]. This figure depicts the 12 domains within the HSS framework developed by the AMA. Reproduced from Borkan et al. (2021) under the CC BY 4.0 license.

In this study, the findings from focus group interviews were mainly interpreted through the following HSS domains: clinical information and health technology, health system improvement, and teamwork. Other HSS domains were not discussed, as they were not explicitly reflected in participants’ experiences.

3. Interpretation of results using the HSS framework

The findings of this study were analyzed in relation to each subdomain of HSS. Descriptions of the subdomains were referenced from the literature [8].

1) Clinical information and health technology

· Topics related to the application of informatics and technology in healthcare delivery, including clinical decision support, documentation, and the use of electronic health records/data to improve health outcomes

· Awareness of real-time data access and decision support for registry management and clinical report analysis

· Recognition of the importance of detecting, reporting, and analyzing safety incidents

“Electronic charts are convenient because I can search for returning patients.” (P1)

“Electronic charts allow me to type quickly.” (P2)

“I like that they include diagnostic codes.” (P3)

Students acknowledged that electronic charts were valuable for recording and managing information. This perception aligns with previous findings suggesting that a compartmentalized UI and Korean-language clinical terminology reduce errors in the charting process and enhance usability [6]. In particular, the ability to systematically store and easily retrieve information on returning patients through electronic charts highlights the role of health information technology in supporting the continuous management and utilization of clinical information.

2) Health system improvement

· Selection of quality indicators and establishment of improvement plans

· Use of a Plan-Do-Study-Act (PDSA) worksheet to verify change ideas

“Electronic charts seem convenient when studying or receiving feedback from professors.” (P3)

Patient information recorded in electronic charts can be anonymized and utilized as study materials for academic or clinic-based learning, thus enhancing feedback opportunities from senior peers or professors. This process contributes to the enhancement of individual competencies and supports ongoing healthcare system improvement.

3) Teamwork

· Involves collaboration among individuals working together to achieve shared goals

· Interprofessional education as an integral component

“I received a handover from senior students in the first year of the main course on how to complete the preliminary chart.” (P1)

“In the student clinic, junior students conducted the preliminary history-taking, while senior students in the main course were responsible for treatment. We divided roles and worked together.” (P2)

“In the preliminary history-taking, the patient’s digestion was marked as normal, but during the main consultation for prescribing, it was found that this was not actually the case.” (P2)

“Paper charts are very difficult to manage when searching for returning patients, and they are often lost. Electronic charts seem to be useful in this regard.” (P2)

The role division and knowledge transfer (handover) across academic years reflect early forms of collaborative teamwork within a student-centered, clinical environment. Electronic charts were seen as a more stable platform for accessing and managing clinical information by reducing the risk of record loss, thus supporting information sharing and teamwork. The stability of electronic charts may contribute to more seamless knowledge handovers and interprofessional collaboration, which are core elements of the HSS ‘teamwork’ domain. In this regard, previous research has also highlighted the importance of teamwork among students during medical volunteering [10], which aligns with the HSS objective of fostering collaboration. The role division across academic years and knowledge transfer that occurs through the use of electronic charts help standardize and share clinical documentation, facilitating collaborative teamwork.

DISCUSSION

The findings of this study revealed several critical issues in the current state of medical record education in Korean medicine colleges. Specifically, the study demonstrated that students primarily acquired documentation skills through informal channels, leading to insufficient competence in structured history-taking and a disconnection between theoretical knowledge and clinical application. For example, although memorizing question lists may help students engage with patients, it does not foster the clinical reasoning skills needed for selecting relevant information for diagnosis and approaching it in a logical, systematic manner. Even senior students reported difficulties in constructing questions efficiently. In the HSS context, the findings highlighted a crucial educational need: the necessity of training students to balance ‘digital literacy’ with ‘humanistic care.’ Effective electronic chart education should include strategies for maintaining patient-centered communication while simultaneously managing high-tech documentation systems.

Furthermore, education on medical documentation using electronic charts aligns with the core and foundational competencies emphasized in HSS. In this study, electronic chart-based training was associated with three key HSS domains (clinical information and health technology, health system improvement, and teamwork). Therefore, integrating electronic chart education into the curriculum would support the principles of HSS, particularly in enhancing clinical information management and promoting systems thinking. Beyond merely teaching data entry, mastering electronic charts allows students to understand how individual patient encounters interact with broader insurance policies and institutional structures. This systems perspective is crucial for comprehending the socio-ecological determinants of health within the HSS framework.

Building on these HSS-aligned principles, this study advocates for the development of a preparatory educational program to equip students with standardized charting competencies prior to clinical clerkships. The proposed program consists of the following sequential stages:

1. Basic training (pre-clinical): Lectures covering the SOAP structure, basic terminology, history-taking methods, and the use of electronic charts

2. Pre-simulation practice (simulation-based practice): Documentation of electronic medical records with standardized patients, team-based learning, and feedback sessions

3. Clinical linkage: Integration of charting education into clinical clerkships

This stepwise program aligns with multiple criteria outlined in KAS2022. For example, basic training provides the foundation for clinical and fundamental skills (P2.5.1), while pre-simulation practice contributes to the establishment of an assessment system that regularly reviews and improves the procedures, structure, and content of the educational program [5].

The proposed preparatory education extends beyond technical training in documentation, incorporating educational considerations related to clinical reasoning, teamwork, and the practical use of health information. In this sense, electronic chart-based documentation training connects with broader discussions about comprehensive clinical education and aligns with the educational goals of HSS in Korean medicine education.

The findings are consistent with those of a comparative study, which demonstrated that the P3 group (senior students) achieved the greatest improvement in scores when using electronic charts. This may reflect the stronger ability of senior students to organize complex information systematically by utilizing the compartmentalized UI of electronic charts, a skill developed through their accumulated clinical experience. Therefore, electronic chart education should be tailored to the learner’s level: for junior students, it should function as a learning tool, whereas for senior students, it should serve as a tool for enhancing work efficiency. A grade-specific educational strategy is required to maximize the benefits of electronic chart education.

CONCLUSION

This study conducted an in-depth analysis of the current state of medical record education in Korean medicine colleges, based on interviews with 19 students. The results revealed that students primarily learned charting through informal channels rather than formal education, which led to challenges in structuring questions systematically and using professional terminology. Students also emphasized the need for basic charting education from the early years and called for the establishment of a standardized educational system. Although electronic charts were acknowledged for their advantages in rapid documentation and systematic information management, students also noted disadvantages, such as difficulties in understanding clinical abbreviations and the restricted flexibility of free-text recording.

To address these issues and support the development of professionalism among future Korean medicine practitioners, it is necessary to establish a systematic educational framework for medical record education. This should go beyond paper chart training and incorporate education on using electronic charts, reflecting their widespread use in actual clinical settings. As indicated by Hong et al., future Korean medicine practitioners must be competent in digital and technological utilization [11]. Therefore, medical record education should no longer be viewed merely as technical training but as a foundational element in shaping the professional identity of future Korean medicine practitioners. Electronic chart education may help students experience and understand the processes of medical record management and patient information handling, thereby providing a vital educational foundation for recognizing the role of medical documentation within clinical contexts.

Ultimately, Korean medicine education must establish a comprehensive framework for clinical performance through structured training in history-taking and medical documentation. In response to broader social changes, it is necessary to redefine educational objectives, apply diverse teaching and learning methods, and continuously enhance overall competencies [12]. A systematic approach to history-taking and medical documentation, combined with education on electronic chart use, has meaningful implications for evaluating the core competencies emphasized in HSS.

In summary, medical record education in Korean medicine colleges should be recognized as an important component in preparing future practitioners for their professional roles, not simply as technical documentation training. By establishing an educational system that allows students to conduct structured history-taking and manage patient information accurately with the consistent use of electronic charts, the quality of clinical education may be improved. This approach also aligns with ongoing discussions on integrated clinical competencies and may help improve the quality of healthcare delivery in Korean medicine. However, potential issues, such as the lack of rapport with patients during electronic chart use, should be considered in educational development. Accordingly, future research should focus on the integration of electronic chart use with CPX and OSCE. These assessments would be essential for ensuring that electronic charting not only enhances documentation but also promotes patient-centered care and interdisciplinary collaboration.

Although this study is limited by its focus on a single institution, it offers a crucial framework for addressing the long-standing fragmentation in traditional medical record education. By integrating electronic charting within the HSS framework, Korean medicine education can effectively bridge the gap between classroom theory and clinical reality. Future research should focus on developing standardized, high-fidelity clinical training modules (e.g., electronic medical record-integrated CPX and OSCE programs). These modules will be essential for cultivating digitally literate, patient-centered medical practitioners and ensuring the sustainability of Korean medicine in a rapidly evolving healthcare environment.