Zavodnick Jillian, Kouvatsos Tasha
Clinical Assistant Professor, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University.
MedEdPORTAL. 2019 Oct 25;15:10849. doi: 10.15766/mep_2374-8265.10849.
The adoption of electronic health records (EHRs) presents new challenges for information gathering, documentation, and patient care. Medical students spend a significant amount of time using the EHR during their clerkship experiences and will continue to do so as they progress to residency. However, formal training varies between institutions and leaves gaps in data-gathering skills, documentation skills, and order entry-these three skills formed the basis for our learning objectives. We designed a workshop using a simulated EHR to teach these skills.
We offered the workshop during a class-wide transition-to-internship course for senior medical students. After a brief didactic, students worked in small groups using a simulated EHR to complete cases addressing each of the three learning objectives. Faculty facilitators assisted groups and then guided a large-group discussion of the challenges encountered during the cases.
Twenty-five senior medical students attended the first optional workshop. Of these students, 66.7% recommended that the workshop continue to be included in the curriculum. Comments from those who recommended otherwise suggested that many of them would recommend the workshop if it used our local EHR (Epic). Correct answers to the factual questions increased for most questions between the pretest and the posttest. Confidence to perform all skills targeted in the learning objectives increased between the pretest and the posttest.
This EHR workshop was well received by senior medical students and increased confidence in EHR skills, including data gathering, documentation, and handling unsolicited information with a plan including order entry.
电子健康记录(EHRs)的采用给信息收集、文档记录和患者护理带来了新的挑战。医学生在实习期间会花费大量时间使用电子健康记录,并且在进入住院医师阶段后仍会继续如此。然而,各机构之间的正规培训存在差异,在数据收集技能、文档记录技能和医嘱录入方面存在差距——这三项技能构成了我们学习目标的基础。我们设计了一个使用模拟电子健康记录的工作坊来教授这些技能。
我们在面向高年级医学生的全年级实习过渡课程中提供了这个工作坊。经过简短的讲解后,学生们分组使用模拟电子健康记录完成病例,以解决三个学习目标中的每一个。教师引导人员协助各小组,然后组织全班讨论在病例过程中遇到的挑战。
25名高年级医学生参加了第一个选修工作坊。在这些学生中,66.7%的人建议该工作坊继续纳入课程。持反对意见的学生表示,如果使用我们当地的电子健康记录(Epic),他们中的许多人会推荐这个工作坊。在预测试和后测试之间,大多数事实性问题的正确答案有所增加。在预测试和后测试之间,对学习目标中所有技能的执行信心有所增强。
这个电子健康记录工作坊受到了高年级医学生的好评,并增强了他们在电子健康记录技能方面的信心,包括数据收集、文档记录以及通过包括医嘱录入在内的计划来处理主动提供的信息。