• Heather L Heiman, Sonya Rasminsky, Jennifer A Bierman, Daniel B Evans, Kathryn G Kinner, Julie Stamos, Zoran Martinovich, and William C McGaghie.
• a Department of Medicine and Augusta Webster, MD, Office of Medical Education , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA.
• Teach Learn Med. 2014 Jan 1; 26 (1): 49-55.

BackgroundMedical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy-paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students' experiences with copy-paste, templates and other "efficiency tools" in EHRs.PurposesWe sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools.MethodsWe surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy-paste, templates, auto-inserted data, and "scribing" (documentation under a supervisor's name).ResultsOverall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers' notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy-paste policy.ConclusionsStudents frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy-paste from other providers, most have observed clinical supervisors doing so.

9 keywords...

hide…