Medical Student Documentation in the Emergency Department in the Electronic Health Record Era-A National Survey.

OBJECTIVES

Implementation of electronic health record (EHR) has generated a new challenge in the practice of medical student documentation in the emergency department (ED). This study discerns both the current practices and consensus opinions of pediatric ED directors and Association of American Medical Colleges (AAMC) student representatives regarding best practices for documentation by medical students in the ED EHR nationwide.

METHODS

The authors conducted a cross-sectional Web-based survey of the directors of academic pediatric EDs and AAMC student representatives using Qualtric survey engine. The survey asked participants to describe their current practices and their opinion regarding the utility of and best practices for medical student documentation in the ED.

RESULTS

Approximately 47% (35/74) of pediatric ED directors and 54% (70/129) of AAMC medical schools' student representatives responded to the survey. Both groups demonstrated similar opinions of the critical importance and advantage of medical students' documentation in the ED (P ≥ 0.99). However, these 2 groups differed in opinion on the impact of medical student documentation on clinical care of the ED patients (P = 0.008). The survey found that 83% of medical students and 74% of ED directors believe that medical students should be documenting in the EHR. The majority of both groups (51% of medical students and 65% of ED directors) preferred a single, combined attending physician-medical student note for clinical documentation.

CONCLUSIONS

This study presents data describing the current practice of medical student documentation in academic pediatric EDs in the United States. There is a strong consensus among educators and students on the usefulness of medical student documenting patient encounters in the ED.