Medical students in some of Island Health’s busiest emergency departments are now able to practice their documenting skills with electronic clinical documentation, thanks to a recommendation from three ER physicians who advocated for an enhancement to the Cerner Electronic Health Record (EHR).
“It has provided an excellent opportunity to practice documenting patient histories and physical exams on a high volume of patients, which is a critical skill to learn during our clerkship year,” said UBC 3rd year medical student Erin Flanagan, who completed a month-long rotation in the ER departments at Royal Jubilee (RJH) and Victoria General Hospital (VGH) on November 21.
Dr. Jason Wale, who works regularly with medical students as an ER physician at Royal Jubilee Hospital (RJH), recommended the change to the Cerner EHR along with two colleagues, Dr. Tracey Stephenson and Dr. Simon Glaude, both of whom work in the ER at Cowichan District Hospital (CDH).
Once medical students have documented information from their patient encounters, Dr. Wale said, “we as preceptors are able to review, edit and add to these notes prior to them being incorporated into the patients’ permanent chart.” Preceptors add final diagnosis and final sign off on student-created notes.
This expanded access allows 3rd and 4th-year medical students to type or dictate their patient history and physical exam findings in FirstNet and Dynamic Documentation, programs housed within the EHR. The enhancement is part of the transformation from paper charting to electronic documentation – one goal for the IHealth project.
Dr. Stephenson said the change to the EHR helps meet another important goal for the IHealth project: providing a clear medical record that can be shared across a continuum of care providers for a single patient.
“This is an opportunity for students to review their notes in real time with their preceptors for enhanced learning, and is infinitely more efficient than different providers documenting in different places as it allows for a cohesive, clear medical record,” she said.
The three physicians who advocated for the enhancement said it would not have been possible without the responsiveness and support of nurse informaticists Amanda Adams and Melanie Tait. “They are doing great work making the transition to Cerner easier on all of us in the ER,” said Dr. Wale.
The enhancement is now live and in use by medical students at RJH, Cowichan District Hospital, VGH, Nanaimo Regional General Hospital, and Oceanside Health Centre.