Electronic health records and clinical documentation in medical residency programs: preparing residents to become master clinicians

Abstract

Abstract Objective The ubiquity of electronic health records (EHRs) has made incorporating EHRs into medical practice an essential component of resident’s training. Patient encounters, an important element of practice, are impacted by EHRs through factors that include increasing documentation requirements. This research sheds light on the role of EHRs on resident clinical skills development with emphasis on their role in patient encounters. Materials and Methods We conducted qualitative semistructured interviews with 32 residents and 13 clinic personnel at an internal medicine residency program in a western US medical school focusing on the resident’s clinic rotation. Results Residents were learning to use the EHR to support and enhance their patient encounters, but one factor making that more challenging for many was the need to address quality measures. Quality measures could shift attention away from the primary reason for the encounter and addressing them consumed time that could have been spent diagnosing and treating the patient’s chief complaint. A willingness to learn on-the-job by asking questions was important for resident development in using the EHR to support their work and improve their clinical skills. Discussion Creating a culture where residents seek guidance on how to use the EHR and incorporate it into their work will support residents on their journey to become master clinicians. Shifting some documentation to the patient and other clinicians may also be necessary to keep from overburdening residents. Conclusion Residency programs must support residents as they develop their clinical skills to practice in a world where EHRs are ubiquitous.