Exploring the qualities of Electronic Health Record medical student documentation
AffiliationMelbourne Graduate School of Education
Melbourne Medical School Collected Works
Document TypeMasters Research thesis
Access StatusOpen Access
© 2016 Lisa Cheshire
Written communication within the health professions has been rapidly changing over the last decade. Implementation of Electronic Health Records (EHR) in health services is now widespread. Medical student teaching and learning of the skills specifically required for EHRs has lagged behind the implementation. Very few original studies have focused on EHR skills and there are no validated measures by which to assess any of the EHR skills students are expected to develop. Our study explored the attributes of quality EHR documentation recorded by medical students, with the purpose of the EHR documentation being the communication between health care professionals to share or transfer the clinical care of a patient. Recently there have been published validated instruments for measuring quality in physician EHR documentation, one being Physician Documentation Quality Instrument (PDQI-9). The purpose of this study was to explore the attributes of quality of EHR documentation written by first-year clinical medical students by building upon existing literature. The PDQI-9 was used as a basis for defining the attributes of quality in EHR documentation as a foundation for assessing and providing feedback on the performance of documentation to medical students. With the focus on assessment, and providing a content validated test domain for assessment in quality EHR documentation, we utilised Kane’s framework for validity to structure the study and a mixed method study design to achieve the depth of exploration required to examine the performance of quality documentation fully. The study was conducted in two stages. In the first stage of the study, an expert panel of assessors applied the PDQI-9 to existing EHR data recorded by first clinical year medical students in a graduate entry program. The assessors both scored the records and justified their grading. Descriptive statistics and thematic analysis were undertaken on the data collected, and the findings triangulated with the literature review. The second stage employed explanatory semi-structured interviews with the expert assessors to better understand the findings of the first stage and reach consensus on a test domain for assessing quality documentation recorded by medical students. Outcomes from our study indicated that the PDQI-9 in its current format was not valid in a medical student setting, however most of the attributes assessed by the PDQI-9 were deemed relevant and meaningful to assess if their interpretations were clarified. In addition, Professionalism of documentation was regarded as a quality attribute. Consensus was reached on modifications that have the potential to improve the validity of the assessment of quality documentation recorded by medical students. Further studies need to complete Kane’s framework of validity for an assessment instrument and collect evidence to broaden the validity of the scoring, the generalization of the assessment items, the extrapolation to the real world and the implications of this assessment for students and health services.
Keywordsmedical student; written communication skills; electronic health records; assessment
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