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Learning Objective 1: The learner will be able to describe ways to adapt student clinical evaluations when using electronic health records (EHR).
Learning Objective 2: The learner will be able to compare and contrast how student documentation is evaluated utilizing a traditional medical record and an electronic health record (EMR).
In an accelerated Bachelor of Science in Nursing Program, two nursing faculty supervising 14 clinical students were faced with an evaluation challenge in the maternal child clinical settings. One pediatric institution provided remote access to the electronic health records (EHR) and limited documentation privileges. This institution provided a three hour mandatory training session for all 14 students and their faculty. When the training was completed, access to the EHR was enabled for student use during six twelve hour clinicals. These same 14 students documented in the obstetrical setting utilizing charting by exception in a traditional medical record. The training related to the obstetrical documentation was provided by the clinical instructor during orientation to the facility. The challenge presented itself when faculty began evaluating the students using a standardized clinical performance evaluation tool. The tool’s documentation critical criteria states, “Communicates accurately verbally and in writing (charting and reporting)”. Adaptation of the evaluation process was accomplished through close collaboration with the clinical faculty. The students were exposed to two forms of documentation that they will encounter in practice. This opportunity exposed students to a form of workflow streamlining and provided a technologically advanced group of students an opportunity to utilize a form of communication which they are accustomed to.