Taking note of the perceived value and impact of medical student chart documentation on education and patient care.
OBJECTIVE
To determine the extent of restrictions to medical student documentation in patients' records and the opinions of medical education leaders about such restrictions' impact on medical student education and patient care.


METHODS
Education deans (n = 126) of medical schools in the United States and Canada were surveyed to determine policies regarding placement of medical student notes in the patient record, the value of medical students' documentation in the medical record, and the use of electronic medical records (EMRs) for patient notes. The instrument was a 23-item anonymous Web survey.


RESULTS
Seventy-nine deans responded. Over 90% believed student notes belong in medical records, but only 42% had a policy regarding this. Ninety-three percent indicated that without student notes, student education would be negatively affected. Fewer (56%) indicated that patient care would be negatively affected. Most thought limiting students' notes would negatively affect several other issues: feeling a part of the team (96%), preparation for internship (95%), and students' sense of involvement (94%). Half (52%) reported that fourth-year students could place notes in paper charts at "all" affiliated hospitals, and 6% reported that fourth-year students could do so at "no" hospitals.


CONCLUSIONS
Although students' ability to enter notes in patients' records is believed to be important for student education, only about half of all hospitals allow all students' notes in the EMR. Policies regarding placement of student notes should be implemented to ensure students' competency in note writing and their value as members of the patient care team.
Friedman
Erica
E
Department of Medical Education and Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA. Erica.Friedman@mssm.edu
Sainte
Michelle
M
Fallar
Robert
R
D002170:Canada; D003479:Curriculum; D004282:Documentation / Q000592:standards*; D004504:Education, Medical, Undergraduate / Q000379:methods*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D016134:Organizational Policy; D013337:Students, Medical; D011795:Surveys and Questionnaires; D014481:United States