Department of Medical Education and Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
Acad Med. 2010 Sep;85(9):1440-4. doi: 10.1097/ACM.0b013e3181eac1e0.
To determine the extent of restrictions to medical student documentation in patients' records and the opinions of medical education leaders about such restrictions' impact on medical student education and patient care.
Education deans (n = 126) of medical schools in the United States and Canada were surveyed to determine policies regarding placement of medical student notes in the patient record, the value of medical students' documentation in the medical record, and the use of electronic medical records (EMRs) for patient notes. The instrument was a 23-item anonymous Web survey.
Seventy-nine deans responded. Over 90% believed student notes belong in medical records, but only 42% had a policy regarding this. Ninety-three percent indicated that without student notes, student education would be negatively affected. Fewer (56%) indicated that patient care would be negatively affected. Most thought limiting students' notes would negatively affect several other issues: feeling a part of the team (96%), preparation for internship (95%), and students' sense of involvement (94%). Half (52%) reported that fourth-year students could place notes in paper charts at "all" affiliated hospitals, and 6% reported that fourth-year students could do so at "no" hospitals.
Although students' ability to enter notes in patients' records is believed to be important for student education, only about half of all hospitals allow all students' notes in the EMR. Policies regarding placement of student notes should be implemented to ensure students' competency in note writing and their value as members of the patient care team.
确定对学生记录中医疗记录的学生记录的限制程度以及医学教育领导人对这些限制对医学生教育和患者护理的影响的意见。
对美国和加拿大医学院的教育院长（n = 126）进行了调查，以确定有关将医学生笔记放入患者记录中的政策，医学生在医疗记录中的记录的价值以及电子病历（EMR）用于患者笔记。该工具是一个包含 23 个项目的匿名网络调查。
79 位院长做出了回应。超过 90％的人认为学生笔记应属于病历，但只有 42％对此有政策规定。93％的人表示，如果没有学生的笔记，学生的教育将受到负面影响。表示患者护理将受到负面影响的人较少（56％）。大多数人认为限制学生的笔记会对其他几个问题产生负面影响：团队成员的感觉（96％），实习前的准备（95％）和学生的参与感（94％）。有一半（52％）的人报告说，四年级学生可以在所有附属医院的纸质图表中记录笔记，而有 6％的人报告说，四年级学生可以在没有医院的情况下进行记录。
尽管学生在患者记录中输入笔记的能力被认为对学生的教育很重要，但只有大约一半的医院允许所有学生的笔记都进入 EMR。应实施有关学生笔记放置的政策，以确保学生具备书写笔记的能力，并使其成为患者护理团队成员的价值。
