Teaching Electronic Health Record Documentation to Medical Students

After reflecting on the recent article “The Electronic Health Record and Education: Rethinking Optimization,”¹ the importance of teaching thoughtful documentation in note writing becomes apparent with the challenges of electronic health record (EHR) use and the current generation of learners. Medical students or new residents may fear that lack of information could cause billing or legal issues, leaving them pulling unnecessary chart information or inaccurate problem/medication lists without even processing the content. Documentation skills begin in medical school and carry into practice. Thus, small steps to formally teach appropriate documentation should be a focus of medical student educators.

The Alliance for Clinical Education led the change in medical training, and in 2012 issued a collaborative statement that called for a new approach of closer assessment of medical students' competency in use of the EHR.² The initiative focuses on the progression from early learner to a soon-to-be resident through the use of educational sessions and a learning environment that has a learner interface with an actual or simulated EHR.²

Educational sessions ranging from fundamental to advanced practice standards in medical documentation will improve future physicians' communication using the EHR. These sessions will provide EHR-specific standard templates and offer examples of high-quality notes. By implementing EHR communication guidelines, medical educators are setting a standard to improve overall note score and reduce note clutter from interns and residents.³

In addition to educational sessions, a simulated EHR environment may offer an alternative way to teach learners about appropriate and accurate documentation in the EHR. Medical schools, such as Oregon Health & Science University, have implemented such a program and demonstrated promising results with students able to identify missing key components from notes; students have also shown increasing comfort with locating, updating, and documenting in the EHR.⁴ With variable levels of medical student involvement in the actual EHR used in the health care settings where they learn, this could provide students with an enhanced interactive experience to develop their EHR documentation skills, and receive feedback on it.

Overall, a dual didactic and simulated approach to teaching note writing would collectively assist in enhancing the EHR documentation of the next generation of physicians. Future physicians need to understand how to communicate and document information in an accurate and useful manner while considering the content being placed in a patient's EHR. In order to ensure this development happens, medical educators must play a key role in ensuring future colleagues are prepared for each level of practice.