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Taking Note of the Perceived Value and Impact of Medical Student Chart Documentation on Education and Patient Care

Friedman, Erica MD; Sainte, Michelle; Fallar, Robert MS

Academic Medicine:
doi: 10.1097/ACM.0b013e3181eac1e0
Clinical Skills
Abstract

Purpose: To determine the extent of restrictions to medical student documentation in patients' records and the opinions of medical education leaders about such restrictions' impact on medical student education and patient care.

Method: Education deans (n = 126) of medical schools in the United States and Canada were surveyed to determine policies regarding placement of medical student notes in the patient record, the value of medical students' documentation in the medical record, and the use of electronic medical records (EMRs) for patient notes. The instrument was a 23-item anonymous Web survey.

Results: Seventy-nine deans responded. Over 90% believed student notes belong in medical records, but only 42% had a policy regarding this. Ninety-three percent indicated that without student notes, student education would be negatively affected. Fewer (56%) indicated that patient care would be negatively affected. Most thought limiting students' notes would negatively affect several other issues: feeling a part of the team (96%), preparation for internship (95%), and students' sense of involvement (94%). Half (52%) reported that fourth-year students could place notes in paper charts at “all” affiliated hospitals, and 6% reported that fourth-year students could do so at “no” hospitals.

Conclusions: Although students' ability to enter notes in patients' records is believed to be important for student education, only about half of all hospitals allow all students' notes in the EMR. Policies regarding placement of student notes should be implemented to ensure students' competency in note writing and their value as members of the patient care team.

Author Information

Dr. Friedman is associate dean for undergraduate medical education and associate professor, Department of Medical Education and Medicine, Mount Sinai School of Medicine, New York, New York.

Ms. Sainte is assistant dean for academic administration, Mount Sinai School of Medicine, New York, New York.

Mr. Fallar is director, Survey Center, The Mount Sinai Hospital, Mount Sinai Medical Center, New York, New York.

Correspondence should be addressed to Dr. Friedman, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1127, New York, NY 10029; telephone: (212) 241-8572; fax: (212) 996-1091; e-mail: Erica.Friedman@mssm.edu.

© 2010 Association of American Medical Colleges