An Electronic Medical Record Pocket Guide for Incoming Internal Medicine Interns: Perceptions and Impact on Patient Information Gathering

Division

West Florida

Hospital

Citrus Memorial Hospital

Document Type

Manuscript

Publication Date

6-1-2023

Keywords

electronic medical record, internship and residency, graduate medical education

Disciplines

Internal Medicine | Medical Education

Abstract

OBJECTIVES: The transition from medical student to intern is associated with a significant increase in workloads and responsibilities. This includes using the electronic medical record (EMR), which can lead to challenges in information gathering and patient care; however, no formal residency interventions exist in the use of an EMR for information gathering, with most EMR training occurring in the clinical setting. The present study aimed to improve information gathering on patient care and enhance the confidence of Internal Medicine interns in information gathering.

METHODS: We performed a pre- and postprospective study in July 2021. All of the Internal Medicine interns at our community hospital were included. A pre- and postassessment to evaluate interns' confidence was distributed to participants during orientation week and at the end of the inpatient Internal Medicine rotation. A pre- and postconfidence assessment was collected at the beginning and end, respectively, of each intern's inpatient Internal Medicine rotation.

RESULTS: Seventeen (85%) interns completed both the preassessment and postassessment. Use of an EMR guide led to a significant increase in completeness of patient information gathering (preassessment: 73.2% ± 18.4% vs post-EMR guide: 94.7% ± 7.4%,

CONCLUSIONS: The use of an EMR guide was well received among Internal Medicine interns and led to increased completeness in patient information gathering. Residency programs may benefit from developing an EMR guide to improving the transition of interns during residency.

Publisher or Conference

Southern Medical Journal

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