Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes.
J Grad Med Educ
; 8(2): 237-40, 2016 May.
Article
en En
| MEDLINE
| ID: mdl-27168894
Background With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training. Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes. Methods Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data. Results A total of 31 out of 32 interns (97%) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary. Conclusions Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Asunto principal:
Registros Electrónicos de Salud
/
Medicina Interna
/
Internado y Residencia
Límite:
Humans
Idioma:
En
Revista:
J Grad Med Educ
Año:
2016
Tipo del documento:
Article
Pais de publicación:
Estados Unidos