Quality patient care is dependent on health care providers' ability to efficiently access and communicate information about the patient.1 The patient medical record, one of the foundations for effective clinical communication, consists of notes documenting the patient's medical history, relevant information about the patient's issues at specific times, suspected medical problems, and management plans. The notes are a window into the physician's thought processes, detailing the patient's differential diagnosis and treatment decisions.2
The ability to communicate effectively is recognized by many accreditation and professional organizations as a critical competency throughout the continuum of medical training. At the medical school level, the Association of American Medical Colleges (AAMC) is clear in their Learning Objectives for Medical Student Education that each medical school “must ensure that before graduation a student will have demonstrated … the ability to communicate effectively, both orally and in writing, with patients, patients' families, colleagues, and others with whom physicians must exchange information in carrying out their responsibilities.”3,4 The United States Medical Licensing Examination Step 2 Clinical Skills (CS) assesses oral and written communication skills and uses standardized patient encounters to determine medical students' competency in effective communication.5 To pass the examination, examinees are expected to communicate effectively with patients, demonstrate appropriate interpersonal skills, and communicate effectively with other health professionals through notes in the medical record.
At the residency program level, the Accreditation Council for Graduate Medical Education (ACGME) defines six core competencies for all residents, one of which refers to interpersonal and communications skills.6,7 The ACGME Outcome Project defines this requirement as follows: “Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information…. Residents are expected to … maintain comprehensive, timely, and legible medical records, if applicable.”6 First-year residents are expected to write clear and efficient notes about their encounters with patients on both inpatient and outpatient services. Residents are under tremendous time pressure, and their notes are a critical part of the patient record and management plan. Developing trainees' communications skills is essential for their ultimate success in independent practice, as data indicate that inadequate communication skills can increase medical errors and a physician's risk for malpractice suits.8
For medical students to learn how to communicate effectively in the patient record, they must practice doing so before graduating to residency. On their clinical rotations, medical students should be active participants in the health care team, interviewing patients, documenting complaints and findings, and serving as patient advocates by communicating patients' issues to the team. In these ways, students facilitate the transfer of information amongst health care team members. In addition, students learn to become competent by practicing and receiving feedback on their clinical skills, including the ability to write chart notes and to reason about diagnostic and therapeutic plans.9,10
The medical record is a critical resource for promoting the education of medical students because it provides access to patient information and educational resources. It also serves as an important venue for assessing medical student competencies. In fact, medical record review is one of the assessment tools described in the ACGME toolbox for guiding assessment of competency in the six core domains.7
On various educator listservs, medical student documentation in the patient record has been a topic of discussion in recent years. In our conversations with other medical educators (Personal communication from Clerkship Directors in Internal Medicine listserv, November 2008), we learned that many hospitals are restricting medical students' ability to write notes in paper and electronic medical records (EMRs). Various reasons for excluding student notes are cited, including incorrect use of abbreviations, inaccurate data and interpretation (diagnoses and management), unsigned notes, and legal problems resulting from these issues (fines, potential for law suits). Educators, however, foresee many potentially negative consequences of these restrictions, including students being unprepared for residency and inadequate opportunities for students to demonstrate and receive feedback on their data-gathering and clinical reasoning skills. At our institution, when one of our affiliate hospitals prevented student documentation in the chart, we learned from student evaluations that they felt they were not a part of the team, were concerned that they wouldn't develop adequate written skills, and received inadequate feedback on their clinical skills.
Over the last decade, more and more data about patients are being documented electronically, including laboratory/serology results, pathology data, and physician notes.11 With the use of the EMR, additional factors increasingly restrict medical student access to patient records. These factors include training requirements for using the EMR, the potential need for additional programming to restrict access to parts of the record (like order writing), and the potential need to provide separate sections in which to place medical student documentation.
Determining the frequency and extent of restrictions to medical student access and documentation in patients' records is an urgent issue, as is gauging the opinions of medical education leaders about the potential impact of such restrictions on medical student education and patient care. A summary of these potential consequences could prove helpful as institutions develop educational policies and work with hospitals to ensure that students are able to participate in the documentation of patient care. We surveyed education deans of medical schools in the United States and Canada to determine their institutional policies regarding placement of medical student notes in the patient record and the perceived value of medical student documentation of patient interactions in the medical record. In addition, we asked about the use of EMRs and its effect on student note placement.
We created a Web-based questionnaire of 23 items, including 5 categorical demographic items. The survey asked about policies and perceptions regarding medical students' notes in general and specifically with respect to EMRs. A five-point Likert scale (1 = very negative, 2 = somewhat negative, 3 = no opinion, 4 = somewhat positive, 5 = very positive) was used to indicate the respondents' beliefs about the effect of excluding students' notes on a specified list of potential issues around patient care and medical student education. The survey was anonymous; however, we had an optional demographic question indicating the respondent's medical school affiliation so that we could eliminate those who answered this question from e-mail reminders about survey completion. All questions were optional and provided the option to answer, “can't assess or don't know.” The survey was submitted to the Mount Sinai institutional review board and was granted exemption status as an educational study.
At the end of 2007, an invitation with a link to the survey was e-mailed to all 126 individuals indicated on the AAMC list of medical school deans. If we sent the survey to someone who was unable to complete it, that person was asked to forward the survey to whoever would be most prepared to answer the questions.
The data were tabulated using WinCross software (Scottsdale, Arizona). Comparisons were made using independent Z tests for percentages.
From the 126 contacted schools, we received 95 responses. However, we removed 16 for the following reasons: More than one member from the institution responded, so all were excluded (6); an institution responded more than once, but the subsequent response was blank and thus excluded (4); or an institution only completed the first question (6). This left a total of 79 usable responses, representing a 63% response rate; however, not all respondents answered every question.
Out of 79 respondents, 76 completed the demographic items. Demographically, the respondents are representative of the AAMC database from 2008. They represented 62% (47) public and 38% (29) private institutions, with a plurality of those institutions (31) having an enrollment of 500 to 749 for all four years. A majority of the institutions (56) had five or more affiliated teaching hospitals, and more than three-quarters were affiliated with public (62 of 82 respondents; 76%) or Veterans Affairs hospitals (61 of 82; 74%) (Table 1). There were no significant differences in answers based on the size of enrollment or type of institution.
Note writing curriculum
Among the 76 respondents who answered the question, 68% (52) indicated they had a “formal didactic curriculum to teach students” how to write and assess their own progress or follow-up notes. The majority focused on these topics during the second and third years of medical school training (Figure 1). We did not ask respondents to elaborate on specifics of their curricula.
Of the 77 respondents who answered the question, 51% (39) reported that their institution did not have a general policy about the placement of students' notes in patient medical records, whereas 42% (32) had a policy and 8% (6) did not know.
The value of medical student note placement in patients' medical records
Nearly all respondents believed that student notes belong in the medical record in both the inpatient and outpatient settings for third- and fourth-year medical students. Regarding third-year students, 91% (71) of respondents believed student notes should be placed in the inpatient record and 89% (69) believed they should be in the outpatient record. For fourth-year students' notes, 96% (74) and 94% (72) of respondents believed they should be placed in the inpatient and outpatient records, respectively.
Of the 76 respondents who answered the question, 93% (71) indicated that failure to allow student notes in the chart would have a negative impact on medical student education (50% or 38 indicated a “very” negative impact, and 43% or 33 indicated a “somewhat” negative impact), whereas 4% (3) indicated this policy would have “no impact” and 3% (2) indicated a “somewhat positive” impact. When provided with a list of possible consequences that could result from excluding medical students' notes from charts, nearly all respondents indicated that each of the consequences would have a negative effect (either “very” or “somewhat” negative) on students' training, including being part of a team and preparation for internship (Figure 2).
In general, 56% (42) of 75 respondents answering the question reported that a lack of student documentation in the medical record would have a negative impact on patient care (4% or 3 indicated a “very” negative impact and 52% or 39 indicated a “somewhat” negative impact), 41% (31) believed it would have “no impact,” and 3% (2) believed it would have a positive impact (either “somewhat” or “very” positive).
When it comes to the potential effects on specific aspects of patient care, there was more variation in the 77 responses we received. The most negatively perceived impacts were the amount of information available about patients' daily issues (86% or 66 indicated a “somewhat” or “very” negative impact) and the health care team's understanding of the patient's current problems (62% or 48 indicated a “very” or “somewhat” negative impact). Conversely, just over one in five (16) indicated there would be a positive effect on (i.e., a decrease in) the opportunity for malpractice suits if student notes are not included (Figure 3).
Availability and impact of EMRs
Just over half (51 or 57%) of the 89 respondents reported that their main hospital uses an EMR. Among these 44 institutions, 66% (29) use the EMR for “all services” in the inpatient setting and 32% (14) for “some services,” whereas 36% (16) use the EMR for “all services” in the outpatient setting and 59% (26) for “some services.” Regarding student access to the EMR, 40% (17) report “full access,” 28% (12) indicate “limited writing access,” and 33% (14) indicate “read only” access.
Three-quarters of 73 responding schools reported that “all” (52%; 38) or “most” (25%; 18) of their affiliated hospitals allowed fourth-year students to include notes in paper charts. However, among 56 responses about allowing student notes in the EMR, notably fewer reported that “all” (36%; 20) or “most” (25%; 14) affiliated hospitals allowed them (P = .0558). Similarly, three-quarters of 73 responding schools reported that “all” (48%; 35) or “most” (29%; 21) of their affiliated hospitals allowed third-year students to include notes in paper charts, but among 57 responses about the EMR, significantly fewer reported that “all” (33%; 19) or “most” (21%; 12) affiliated hospitals allowed student notes in the EMR (P = .0088) (Figure 4).
The questionnaire presented a list of potential concerns in allowing student notes in the EMR and asked which, if any, were concerns. Of the 63 responses, billing (62%; 39) was the most frequently indicated concern, followed by the need for cosignature (59%; 37), concern about liability (56%; 35), incorrect factual information that could mislead other health care providers (51%; 32), and Joint Commission for Accreditation of Hospital Organization issues of incorrect chart documentation (40%; 25). Interestingly, 58% (42) of 72 respondents reported that there was a mechanism at their main hospital to ensure cosignature in a paper record; however, just 35% (20) of 57 respondents replied similarly regarding the EMR.
Our survey data from a majority of the education deans of North American medical schools support the accepted belief that medical student notes are a valuable part of the patient record. Respondents agreed that the notes enhance the students' education and the role of the medical student on the patient care team, as well as the team's ability to provide care to the patient. Sixty-eight percent (52) of responding medical schools had a framework for teaching and assessing note writing skills. However, less than half had a general policy about the placement of students' notes in the chart. Additionally, 56% (44) reported that an EMR is used in their main hospital. Among affiliated hospitals, many more allow students' notes in paper charts than in the EMR. In fact, just over 10% reported that none of their affiliated hospitals allowed student notes in the EMR. One limitation of our study is that, although respondents could indicate that affiliates did not allow access to the EMR, we did not follow up to ask if this was a policy or a reflection of the lack of an EMR.
Overall, the results indicate that deans perceive that preventing medical students from adding notes to patients' records has a more negative impact on student education than on patient care. Conversely, few see any positive impacts when student notes are not included in the charts. The most prevalent patient care concerns leading to restricting medical student notes in EMRs relate to billing issues, problems with the requirement of an attending cosignature, and the theoretical concern of increased medical liability. Because of hospital policies around these issues, it is complicated to ensure that students have access to patients' EMRs so that they can communicate their findings to the patient care team. Because there are multiple concerns regarding note placement, few medical schools have mandatory policies about student note placement.
Many medical schools are now creating competency-based curricula to align with the ACGME competencies for residents. As medical schools move toward one set of competencies along the continuum from medical school through residency, it becomes increasingly important to ensure that basic communication skills are achieved prior to starting residency. Because of the additional logistical issues involved with medical students accessing an EMR, as more hospitals move to an EMR, this may increasingly adversely affect the development of medical students' written communication skills. One way to assess this impact would be to follow medical students' failure rates on the written communication section of Step 2 CS over time. Another mechanism would be for medical schools to track their graduates' note writing skills by surveying residency program directors. This would help medical schools determine how their current restrictions influence their graduates' written communication skills. According to the 1999 AAMC publication on “Communication in Medicine,”4 medical schools should develop rigorous, standardized assessments of students' written communication skills and document any changes potentially caused by limitations in requirements for note writing and feedback. If restrictions in student note placement continue, it may be crucial to develop and implement clear policies that allow students to document in the patient record and contribute to the care of their patients.
One limitation of this study is that, although we polled the deans, it is unclear who actually responded (the survey indicated they could forward it to whoever could best answer). Our data may not represent the responses of the deans or policy makers at each medical school and also may not represent the perceptions of those on the front lines (e.g., attendings and residents). Responses also do not translate into actions. Championing the educational benefits of medical students' patient notes may be of insignificant importance compared with a medical school's risk of disaffiliation with hospitals that do not allow medical students to place notes in their patient's records. As previously mentioned, another limitation is that our survey did not include follow-up questions to clarify some of the responses. One final limitation is that we surveyed medical schools about how affiliated hospitals may or may not limit student access to the notes. It would be interesting to also survey affiliated hospital administrators to gain their perspectives on why access for student notes may be limited.
One of the critical medical school graduation competencies is written communication skills. Our data show that restricting students' ability to write notes in patients' charts has potentially significant consequences to student competencies and patient care. There are currently restrictions to note placement in paper charts and even greater restrictions when EMRs are used. National organizations such as the AAMC, the Liaison Committee for Medical Education, or the Alliance of Clinical Educators (ACE) should develop recommendations requiring that student notes be evaluated and placed in the patient medical record. This would enable the medical school leadership to pressure hospitals to eliminate preventing students from documenting their findings in the patient chart. Additionally, educators, program directors, or a taskforce through ACE should create guidelines for specific note writing competencies (for both outpatient and inpatient records) and tools for teaching and evaluating these competencies so that we can standardize documentation of these proficiencies. These skills contribute to patient care and the development of important requisite competencies for entering interns.
The survey was submitted to the Mount Sinai institutional review board and was granted exemption status as an educational study.
The abstract of an earlier version of this article was presented at the 2008 Association of American Medical Colleges Annual Meeting, San Antonio, Texas.