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Article review: Teaching documentation on electronic medical records

Posted Jan 10 2011 12:00am

Emergency departments and inpatient services increasingly are implementing electronic medical records (EMR) for patient care documentation. Students are infrequently taught how to document on EMRs, partly because some institutions bar students from typing on the official chart.

This commentary proposes using the RIME approach, made famous by Dr. Lou Pangaro. I reviewed RIME in an  earlier post here . Briefly, you can categorize learners in the ED as a ReporterInterpreterManager, and Educator.
Similarly you can evaluate a learner's ability to document in the EMR using a similar approach:
  • Reporter: Enters clinical data accurately, avoiding cut-and-pasting elements
  • Interpreter: Assesses/explains the data and incorporates into the EMR note
  • Manager: Assimilates the data and articulates a logical management plan
  • Educator: Modifies management plan based on evidence-based literature, clinical support tools, and patient preferences

Summary table from article  (click to open larger version)

What is the appropriate skill level in EMR documentation for a third- or fourth-year medical student? 
According to the authors, MS3's should be proficient at being a Reporter, and MS4's should be proficient at being an Interpreter.
  EMR proficiency chart from article  (click to open larger version)
Reference Stephens MB, Gimbel RW, Pangaro L. Commentary: The RIME/EMR Scheme: An Educational Approach to Clinical Documentation in Electronic Medical Records. Acad Med. 2011, 86(1):11-14. PMID:  21191202
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