医学生在住院临床实习期间使用电子病历和纸质病历的情况：一项全国性纵向研究的结果。
Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study.
机构信息
L.M. Foster is data analyst, National Board of Medical Examiners, Philadelphia, Pennsylvania. M.M. Cuddy is measurement scientist, National Board of Medical Examiners, Philadelphia, Pennsylvania. D.B. Swanson is vice president of academic programs and services, American Board of Medical Specialties, Chicago, Illinois, and professor of medical education, University of Melbourne, Melbourne, Victoria, Australia. K.Z. Holtzman is director, Assessment and International Operations, American Board of Medical Specialties, Chicago, Illinois. M.M. Hammoud is professor of obstetrics and gynecology and professor of learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan. P.M. Wallach is executive associate dean for educational affairs and institutional improvement and professor of medicine, Indiana University School of Medicine, Indianapolis, Indiana.
出版信息
Acad Med. 2018 Nov;93(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 57th Annual Research in Medical Education Sessions):S14-S20. doi: 10.1097/ACM.0000000000002376.
PURPOSE
An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined.
METHOD
An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences.
RESULTS
The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining.
CONCLUSIONS
Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.
目的
医学教育的一个重要目标是教导学生安全有效地使用电子健康记录 (EHR)。本研究的目的是使用全国样本研究医学生在核心住院临床实习期间使用 EHR 的情况。同样也检查了纸质健康记录 (PHR)。
方法
在完成美国医师执照考试第 2 步临床知识部分后，向美国 2012 年至 2016 年毕业的 17202 名医学生在线调查了住院部分核心实习中使用健康记录的情况。计算了学生在各个实习中从事各种健康记录活动的平均百分比，并使用方差分析来检查差异。
结果
学生访问或输入 EHR 信息的实习平均百分比从 78%增加到 93%和 59%增加到 72%。对于使用 EHR 的学生，他们在实习中输入信息的平均百分比保持在 76%不变。学生在大多数实习中都记录了笔记，并且随着时间的推移有所增加。然而，学生在不到四分之一的实习中下达医嘱，随着时间的推移，这一比例有所下降。使用 PHR 的实习百分比较低且呈下降趋势。
结论
尽管学生在大多数住院核心实习中使用了 EHR，但他们获得的与医嘱和记录书写相关的教育经验有限，这可能导致他们未来的培训和实践准备不足。
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