Medical students' observations, practices, and attitudes regarding electronic health record documentation Journal Article

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Authors: Heiman, H. L.; Rasminsky, S.; Bierman, J. A.; Evans, D. B.; Kinner, K. G.; Stamos, J.; Martinovich, Z.; McGaghie, W. C.
Article Title: Medical students' observations, practices, and attitudes regarding electronic health record documentation
Abstract: Background: Medical 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. Purposes: We sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We 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). Results: Overall, 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. Conclusions: Students 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.
Journal Title: Teaching and learning in medicine
Volume: 26
Issue: 1
ISSN: 1532-8015; 1040-1334
Publisher: Unknown  
Journal Place: United States
Date Published: 2014
Start Page: 49
End Page: 55
Language: eng
DOI/URL:

10.1080/10401334.2013.857337

10.1080/10401334.2013.857337
Notes: JID: 8910884; ppublish