In our last post, we wrote about why using an Academic EHR during clinical rotations can be extremely useful for both students and instructors. If you've already decided that your school is going to get students charting on an Academic EHR while visiting clinical sites, we're here to give you a few concrete examples of how that can be done. First, we suggest making sure your system is web-based so students can actively chart during their visit on a tablet or computer that's available. Depending on your clinical site, they may allow students to chart on their own tablet or laptop as well. If that's not possible, students can always enter charting after their visit.
Before having students start charting during clinicals, it's a good idea to do a HIPPA/JACO/etc. review so they know to avoid recording any identifiers like the patient's name, phone number, address or room number.
1. Charting of Care: Just like students will be doing in real life, they should be charting every action they take. If they insert an IV or catheter, this is the time to get in the habit of recording that information. As we all know "if it isn't in the chart, it didn't happen!". As students chart their daily activities during clinicals, instructors can review that work so they have an understanding of what the student is, or is not, being exposed to during their visits.
2. Care Plans: Instead of creating a lengthy care plan on a piece of paper the night after clinicals and then never looking at it again, students can create a care plan in your Academic EHR system during or after their clinical visit. That way, when they open up the chart the following visit, they have access to their care plan and can modify it or act on it as they need to. This will also give instructors a way to review care plans that students enter and grade or comment on the students' work.
3. Review: Every so often a student will come across a great example of a patient during clinical rotations. For the student assigned to the patient, this is a great opportunity to learn more about a condition or practice a less common procedure. However, the experience typically ends with that particular student. By having students use an Academic EHR System, instructors can review student work and grade or comment on every chart. They can also open patient charts that were submitted by students and display that chart on a projector or SmartBoard during class. That allows the instructor and go over what happened with that patient or have the rest of the class practice a procedure in the Skills Lab after reviewing the case based on the charting completed from that visit. The experience is never lost - it's now in the chart that instructors have access to and can open in class.
Hopefully that gives you some ideas for how students can use an Academic EHR during clinical rotations. We'd love to hear how your school handles this as well. Leave a comment if you have an idea to add!