MedicalRecord

Do you have medical students rotating in your Emergency Department? Are they allowed to document in the medical record?

Charting in the medical record is the cornerstone of clinical communication. You document your findings, your clinical reasoning, and management plan. The medical record allows communication amongst providers. Chart documentation is a crucial skill that every medical student should know, as stated by the Association of American Medical Colleges (AAMC).

However, there is a growing trend whereby medical students are no longer being allowed to document in the medical record. I find this alarming, because this was often how I assessed their knowledge and clinical competency. Various reasons for excluding students include:

  • Medicolegal risk
  • Inaccurate information
  • Unsigned notes
  • Inability to bill and be reimbursed

This is especially true for institutions where the medical record is electronic and not paper-based. These electronic medical records (EMR) tend to lock-out and restrict access by students.

This Academic Medicine study reports results from a 23-item survey of medical school deans in the U.S. and Canada. The response rate was 63% (79/126).

  • 96% and 94% of respondents stated that 4th-year student notes should be included in the inpatient and outpatient records, respectively.

The respondents felt that a student’s inability to document in the chart would have negative consequences:

  • Not feeling a part of the team (96%)
  • Inadequate preparation for internship (95%)
  • Lack of a sense of being involved (94%)

Bottom line – Getting to the point

Medical school deans overwhelmingly support that medical students’ notes be included as part of the patient’s official medical chart from an educational standpoint. Furthermore, it promotes a sense of inclusion on the medical team.

The authors advocate that governing organizations such as AAMC, the Liaison Committee for Medical Education (LCME), or the Alliance of Clinical Educators (ACE) should officially recommend that student notes be included in the patient chart.

I totally agree. It isn’t like entering PGY-1 residents can magically document better now that they have just graduated from medical school. Medical students should be taught how to and be allowed to document in the chart, with appropriate guidance. The starting PGY-1 residents are already stressed out in adapting to a new system with new responsibilities. There’s no need to add chart documentation to their list of things to learn!

Reference
Friedman E, Sainte M, & Fallar R (2010). Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Academic medicine : journal of the Association of American Medical Colleges, 85 (9), 1440-4 PMID: 20736671.
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD

@M_Lin

Professor of Emerg Med at UCSF-Zuckerberg San Francisco General. Founder of ALiEM @aliemteam #PostitPearls https://t.co/7v7cgJqNEn
Michelle Lin, MD