Teaching Electronic Health Record Documentation to Medical Students

Teaching Pharmacy Students to Write in the Medical Record

To practice pharmaceutical care, pharmacists will need to communicate and document their recommendations in the medical record. We incorporated instruction on the principles of chart documentation into an elective on primary care therapeutics. Students developed a patient specific care plan and wrote a “chart note” to document their assessment and recommendations. Performance criteria for notes...

Improving documentation of quality measures in the electronic health record.

PURPOSE Oncology quality measures provide an important tool to evaluate care received by cancer patients. These measures are frequently addressed by oncology nurse practitioners (NPs). NP documentation of quality oncology practice initiative (QOPI) measures in the electronic health record (EHR) is evaluated in this study. DATA SOURCES NP documentation of specific QOPI measures before and afte...

Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation.

In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to...

Clinical Documentation in Emergency Departments : Integrating paper - based documentation into the electronic medical record

Factors in Medical Student Beliefs about Electronic Health Record Use Factors in Medical Student Beliefs about Electronic Health Record Use

Healthcare providers’ ongoing investment in electronic health records (EHRs) necessitates an understanding of physicians’ expectations about using EHRs. Such understanding may aid educators and administrators when utilizing scarce resources during EHR training and implementation activities. This study aimed to link individual medical student characteristics to their perceptions of EHRs’ ease of...