Commentary: The RIME/EMR Scheme: An Educational Approach to Clinical Documentation in Electronic Medical Records

Abstract

Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and clinical documentation skills. EMRs also affect how clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter-Interpreter-Manager-Educator scheme is one approach to teach and evaluate clinical documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.

Ähnliche Arbeiten