Simulated Electronic Health Record Research Articles

Clinician perspectives on how situational context and augmented intelligence design features impact perceived usefulness of sepsis prediction scores embedded within a simulated electronic health record.

Obtain clinicians' perspectives on early warning scores (EWS) use within context of clinical cases. We developed cases mimicking sepsis situations. De-identified data, synthesized physician notes, and EWS representing deterioration risk were displayed in a simulated EHR for analysis. Twelve clinicians participated in semi-structured interviews to ascertain perspectives across four domains: (1) Familiarity with and understanding of artificial intelligence (AI), prediction models and risk scores; (2) Clinical reasoning processes; (3) Impression and response to EWS; and (4) Interface design. Transcripts were coded and analyzed using content and thematic analysis. Analysis revealed clinicians have experience but limited AI and prediction/risk modeling understanding. Case assessments were primarily based on clinical data. EWS went unmentioned during initial case analysis; although when prompted to comment on it, they discussed it in subsequent cases. Clinicians were unsure how to interpret or apply the EWS, and desired evidence on its derivation and validation. Design recommendations centered around EWS display in multi-patient lists for triage, and EWS trends within the patient record. Themes included a "Trust but Verify" approach to AI and early warning information, dichotomy that EWS is helpful for triage yet has disproportional signal-to-high noise ratio, and action driven by clinical judgment, not the EWS. Clinicians were unsure of how to apply EWS, acted on clinical data, desired score composition and validation information, and felt EWS was most useful when embedded in multi-patient views. Systems providing interactive visualization may facilitate EWS transparency and increase confidence in AI-generated information.

Benefits of Using a Free Cloud-Based Electronic Health Record for Simulation in a Baccalaureate Nursing Program.

The rising cost of simulated electronic health record (EHR) software for students in a baccalaureate nursing program was risking student success. The need for faculty to decrease this financial burden on students was apparent. Simulation faculty created a free and cloud-based simulated EHR. High-fidelity features of the simulated EHR include barcode scanning capabilities and real-time diagnostic results. Students report that the simulated EHR is easy to navigate and they are particularly satisfied with the free cost. The EHR template, which can be customized for each simulated patient, and is now being used inside the classroom as an active learning strategy.

Identifying Usability Challenges in Electronic Medication Administration Record Design Through Scenario-Based Evaluations: A Pilot Study

Hospitals have more incentives than ever to make nurse-facing technologies usable. However, the complexities of the nursing workflow are not supported by health information technology. This investigation aimed to identify usability challenges in a hospital system’s electronic medication administration record (eMAR). The research team developed scenarios that nurses completed using a simulated electronic health record. Data was qualitatively analyzed using the reflexive thematic analysis method. Three female medical-surgical nurses participated in the study. Qualitative analysis identified five themes in the data including: 1) essential information exists outside of the eMAR, 2) unable to view future medications, 3) information lost with unit transfer, 4) unable to document home medications, 5) certain medications delay sequential orders. Future usability evaluations of the eMAR should continue to look for poor usability, identify solutions, and consider the process for how individual hospitals can apply these usability evaluations to their own eMARs.

User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study.

Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities. In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting. We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS. Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary. User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.

Assessing a Pediatric Nursing Simulation with an Electronic Health Record, Video-Assisted Debrief, and Minimized Group Sizes

BackgroundSimulated patient experiences are accepted as an effective teaching strategy in nursing education; however, variability remains in the literature surrounding simulation delivery best practices. MethodThis quasi-experimental study investigated the effect of simulation delivery variables such as video-assisted debriefing, simulated electronic health records (EHR), and smaller simulation groups on students’ perception of learning in a pediatric simulation. ResultsNo differences were found among variables related to students’ perceptions of meeting the simulation learning objectives; however, students rated elements of debriefing effectiveness higher in groups utilizing a simulated EHR. ConclusionSimulated EHRs may enhance students’ perception of simulation effectiveness and should be incorporated into nursing simulation as able.

Impact of Implementing Simulated Electronic Health Record into Nurse Aide CourseImpact of Implementing Simulated Electronic Health Record into Nurse Aide Course

Electronic health records are an integral part of the healthcare system and have been found to improve access to health services, increase efficiency within the health care system, &amp;amp; enhance the safety and quality of patient care (Kleib et al., 2021). Despite how vital EHRs are in healthcare, research found that only 20% of nurses surveyed had EHR training within the school (Repsha et al., 2020). When nursing students do receive simulated EHR training their documenting and critical thinking skills have shown to improve (Everett-Thomas et al., 2021). Students also report high satisfaction with use of the simulated EHR system. While there is research on the impact of simulated EHR education on nursing students, there is limited information on the impact of simulated EHR education on nurse aide students. It is anticipated that nurse aide students who experienced simulated EHR training within their nurse aide course reported higher confidence levels when using EHR systems in the clinical environment and when in the workforce than nurse aide students who did not receive simulated EHR training

Comparison of Student Pharmacists’ Knowledge Retention Utilizing Electronic Health Records Versus Simultaneously Completing Simulated Experiences

Objective. The purpose of this study was to determine whether the addition of standardized patients or the addition of interprofessional student teams with standardized patients to the use of a simulated electronic health record improved student knowledge retention and perceptions.Methods. This was a prospective cohort study assessing three cohorts of first-year student pharmacists in pharmacy skills laboratory activities that occurred in 2018, 2019, and 2021. The primary objective of the study was to compare knowledge retention of the case material between groups at one month. Each year, an element of simulated experience was added onto the previous year's case. In 2018, students completed the case using only the electronic health record web application. In 2019, the previous year's experience was combined with an objective structured clinical examination (OSCE) with standardized patients. In 2021, the 2019 experience was supplemented with student physician assistants. Case scores and student perceptions were also compared between groups.Results. Of the 260 potential participants, 238 students were included in the primary analysis. Results showed that with the addition of interprofessional team-based care and standardized patients, significant improvement was demonstrated in knowledge retention assessments at one month. Mean knowledge retention assessment scores for the 2018, 2019, and 2021 groups were 63.8%, 71.7%, and 76.1%, respectively. Significant improvement was also found in student perceptions.Conclusion. Adding standardized patients and interprofessional team-based care to a pharmacy skills laboratory that uses a simulated electronic health record significantly improved student knowledge retention and perceptions.

Simulated Electronic Health Record Chart Audit: A Relevant Clinical Activity.

Simulated Electronic Health Record Chart Audit: A Relevant Clinical Activity.

Keeping synthetic patients on track: feedback mechanisms to mitigate performance drift in longitudinal health data simulation.

Synthetic data are increasingly relied upon to share electronic health record (EHR) data while maintaining patient privacy. Current simulation methods can generate longitudinal data, but the results are unreliable for several reasons. First, the synthetic data drifts from the real data distribution over time. Second, the typical approach to quality assessment, which is based on the extent to which real records can be distinguished from synthetic records using a critic model, often fails to recognize poor simulation results. In this article, we introduce a longitudinal simulation framework, called LS-EHR, which addresses these issues. LS-EHR enhances simulation through conditional fuzzing and regularization, rejection sampling, and prior knowledge embedding. We compare LS-EHR to the state-of-the-art using data from 60 000 EHRs from Vanderbilt University Medical Center (VUMC) and the All of Us Research Program. We assess discrimination between real and synthetic data over time. We evaluate the generation process and critic model using the area under the receiver operating characteristic curve (AUROC). For the critic, a higher value indicates a more robust model for quality assessment. For the generation process, a lower value indicates better synthetic data quality. The LS-EHR critic improves discrimination AUROC from 0.655 to 0.909 and 0.692 to 0.918 for VUMC and All of Us data, respectively. By using the new critic, the LS-EHR generation model reduces the AUROC from 0.909 to 0.758 and 0.918 to 0.806. LS-EHR can substantially improve the usability of simulated longitudinal EHR data.

Affective Distancing Associated with Second Language Use Influences Response to Health Information

Health care delivery depends on effective provider–patient communication. An important issue is whether and how this communication differs for second language (SL) patients. While understanding health information can be impaired by limited English proficiency, we examined a potential benefit of SL use. SL users may be “affectively distanced”, with weaker emotional reactions to content presented in a foreign versus native language (NL). This distancing may have important implications for understanding, and for making decisions and judgements about health information to the extent these processes involve affective responses. For example, patients may respond to diagnostic test results indicating risk of illness with less intense negative affect if the information is presented in their SL. Language differences in affective response may in turn attenuate risk perception for SL versus NL users, with perceived risk being lower while the objective risk associated with test results increases, as predicted by the ‘risk as feelings’ view of risk perception, where perceived risk is based on affective response to the information. On the other hand, risk perception may be more calibrated with objective risk for SL users to the extent that affective distancing encourages SL users to rely on deliberative rather than affective-based, intuitive processes related to risk perception. SL use may also influence attitudes toward and intentions to perform behaviors that address risk because these processes are driven in part by risk perception and memory for the risk information. These processes may also depend on numeracy, defined as the ability to make sense of and rationalize numbers, because it influences risk perception. We tested these predictions in the context of a simulated Electronic Health Record (EHR) patient portal, in which participants were presented diagnostic test results in English from fictional patients. Native English speakers (n = 25), and native Mandarin speakers with higher numeracy (n = 25) and lower numeracy (n = 28) participated in the study. Consistent with the ‘affective distancing’ effect, SL participants with either higher or lower numeracy demonstrated a flatter slope for positive and negative affective responses to the test results compared to NL participants. Moreover, SL participants reported greater perceived risk than NL participants did as objective risk rose. A similar pattern occurred for attitudes toward and intentions to perform behaviors that addressed this risk, especially for treatment health behaviors. On the other hand, language did not influence memory for risk-related information. Our findings extend the affective distancing effect associated with SL use to the health domain and show that this effect influences risk perception and behavioral intentions beyond memory recall and numeracy skills.

Traditional Lecture versus Case-Based Learning in a Therapeutic Drug Monitoring Course within an Integrated Pharmacy Curriculum.

Background: Case-based learning has been shown to increase student perception and performance in multiple topics in pharmacy education. However, no studies have evaluated the impact of virtual patients and case-based learning on student knowledge and knowledge retention of therapeutic drug monitoring and dosing. Innovation: Due to a curriculum overhaul promoting integration and application-based learning, the traditional third-year (P3) therapeutic drug monitoring course was reduced from four (4) credit hours to two (2), in order to add time to pharmacotherapy and skills labs. In order to adapt to this change, the course was shifted to a case-based learning format utilizing virtual patients within a simulated electronic health record (EHR) where the course grade distribution shifted in favor of patient cases versus exam questions. An analysis of student knowledge and knowledge retention of antibiotic dosing and monitoring was conducted comparing students who completed the traditional course versus those who completed the case-based course. Findings: Despite the decrease in credit hours, there was no significant difference shown in the initial knowledge assessment between the traditional and case-based courses (87.0 vs 85.5%). Knowledge retention actually improved in the students who completed the case-based course (78.1% vs 82.5%). Conclusion: Utilizing case-based instruction to teach antibiotic dosing and monitoring was successful in preparing students for these skills during their experiential rotations. Even though students had half the instruction time, they were able to perform calculations and retain knowledge as well as students in the traditional curriculum.

Usability and Acceptability of Clinical Decision Support Based on the KIIDS-TBI Tool for Children with Mild Traumatic Brain Injuries and Intracranial Injuries.

The Kids Intracranial Injury Decision Support tool for Traumatic Brain Injury (KIIDS-TBI) tool is a validated risk prediction model for managing children with mild traumatic brain injuries (mTBI) and intracranial injuries. Electronic clinical decision support (CDS) may facilitate the clinical implementation of this evidence-based guidance. Our objective was to evaluate the acceptability and usability of an electronic CDS tool for managing children with mTBI and intracranial injuries. Emergency medicine and neurosurgery physicians (10 each) from 10 hospitals in the United States were recruited to participate in usability testing of a novel CDS prototype in a simulated electronic health record environment. Testing included a think-aloud protocol, an acceptability and usability survey, and a semi-structured interview. The prototype was updated twice during testing to reflect user feedback. Usability problems recorded in the videos were categorized using content analysis. Interview transcripts were analyzed using thematic analysis. Among the 20 participants, most worked at teaching hospitals (80%), freestanding children's hospitals (95%), and level-1 trauma centers (75%). During the two prototype updates, problems with clarity of terminology and navigating through the CDS interface were identified and corrected. Corresponding to these changes, the number of usability problems decreased from 35 in phase 1 to 8 in phase 3 and the number of mistakes made decreased from 18 (phase 1) to 2 (phase 3). Through the survey, participants found the tool easy to use (90%), useful for determining a patient's level of care (95%), and likely to improve resource use (90%) and patient safety (79%). Interview themes related to the CDS's ability to support evidence-based decision-making and improve clinical workflow proposed implementation strategies and potential pitfalls. After iterative evaluation and refinement, the KIIDS-TBI CDS tool was found to be highly usable and useful for aiding the management of children with mTBI and intracranial injuries.

491 Usability and Acceptability of Clinical Decision Support for Children with Mild Traumatic Brain Injuries and Intracranial Injuries: A Mixed Methods Study

INTRODUCTION: Electronic clinical decision support (CDS) may improve the safe, evidence-based management of children with mild traumatic brain injuries (mTBI) and intracranial injuries. METHODS: Emergency medicine and neurosurgery physicians were recruited to participate in study sessions to test the usability and acceptability of a novel CDS prototype in a simulated electronic health record environment. Testing sessions included interacting with the tool using three simulated clinical cases (https://head-injury-risk-predictor.web.app/case-1.htmlt), a think-aloud protocol, an acceptability and usability survey, and a semi-structured interview. The prototype was updated twice during testing (phases 1-3) to reflect user feedback. Usability problems were categorized and quantified using content analysis and reported with a descriptive summary. The semi-structured interviews were analyzed using thematic analysis. RESULTS: Twenty physicians (10 each from neurosurgery and emergency medicine) were recruited from nine separate hospitals. Most participants worked at teaching hospitals (80%) and level 1 trauma centers (75%). During the prototype updates, problems with clarity of terminology and wording were identified and corrected, along with problems navigating through and using the CDS interface. Corresponding to these changes, the number of usability problems dropped from 35 in phase 1 to 8 in phase 3, and the number of mistakes made went from 18 in phase 1 to 2 in phase 3. Through the survey, most participants found the tool easy to use (90%), useful for determining a patient’s level of care (95%), and likely to improve resource use (90%) and patient safety (79%). Major interview themes related to the CDS’s ability to support evidence-based decision-making and improve clinical workflow, proposed implementation strategies, and potential pitfalls to avoid. CONCLUSION: After the iterative evaluation and refinement, the elctronic CDS tool was found to be highly usable and useful for aiding the management of children with mTBI and intracranial injuries.

Integrating the Electronic Health Record Into Patient Encounters: An Introductory Standardized Patient Exercise for Preclinical Medical Students.

IntroductionIncreasingly, use of the electronic health record (EHR) is interwoven into even the most basic patient care tasks. Accordingly, learning how to utilize the EHR during patient encounters is important for medical students as they develop their clinical skills. Existing EHR curricula have focused primarily on doctor-patient relationship skills. We developed a session for our preclinical students on EHR-related doctor-patient relationship skills as well as on using the EHR to verify data and focus one's history taking.MethodsWe developed student notes, three training videos, four standardized patient (SP) cases, and a simplified, simulated EHR based on these cases. Students reviewed the notes and videos prior to class. During class, students practiced EHR-related communication and data-collection strategies by interviewing an SP while interacting with the simulated EHR. Following each encounter, students received feedback from a small group of peers and faculty.ResultsTwo-hundred eighty-nine second-year medical students participated this session in 2019 and 2020, and 27 (19%, 2019) and 40 (28%, 2020) students, respectively, completed the postsession evaluation. Most respondents rated the SP activity as extremely or quite effective for practicing doctor-patient relationship strategies while interacting with the EHR (89%, 2019; 83%, 2020) and for practicing verification of EHR data during a patient encounter (81%, 2019; 86%, 2020).DiscussionThis training session was effective for introducing preclinical medical students to fundamental concepts and skills related to incorporating the EHR into patient encounters and offers a low-cost approach to teaching early medical students these important skills.

Nursing Informatics Competency After Experiencing Simulated Electronic Health Records: Descriptive Study.

Nursing has embraced flexible online advanced education as a means of increasing the supply of nurse professionals. Virtual simulation and other adaptive learning technologies enhance learning efficiency and student outcomes. A simulated electronic health record (DocuCare) was adopted in an online graduate nursing informatics course. An assignment using DocuCare to learn core concepts of nursing informatics was developed for graduate students enrolled in a nursing informatics course. A validated standard informatics survey instrument was used to measure three individual domains (basic computer skills, roles, and advanced computer skills (clinical informatics)) as well as the combined informatics competency level. Overall, the nursing informatics competency level was between competent and proficient; basic computer skills and roles were above proficient; and advanced computer skills (clinical informatics) fell between competence and proficient levels.

Utilising a simulated clinical rotation elective to prepare pharmacy students for experiential education

Objective: The purpose of this study was to evaluate the impact of an Introduction to Internal Medicine (ITIM) elective course on student preparedness for experiential education. Methods: A one-credit elective was offered to second and third-year professional students. It was designed to simulate a typical day as a fourth-year student on rotation while utilising a simulated electronic health record. Upon completion of the course, a survey was sent to assess student preparedness for rotational activities. The students’ reported level of preparedness was compared to their preceptors’ assessment of these same survey items. Results: Thirty-six students and their preceptors responded to the survey. Students rated their preparedness highly, with 80% responding as moderately prepared or higher in navigating a patient chart, identifying patients’ problems, presenting a patient, and identifying treatments for common disease states. Preceptors also noted that over 90% of the students were moderately or much better prepared than students who did not complete the elective. Conclusion: Students completing the ITIM elective course demonstrated high levels of preparedness for a variety of rotational activities from patient care to professional communication.

Implementation and justification of a curriculum-wide electronic health record platform

Background and purposeIn order to develop practice-ready pharmacists as mandated by the Accreditation Council for Pharmacy Education Accreditation Standards, exposing students to health information technologies used in clinical practice, like electronic health records (EHRs), is imperative. While the benefits of using EHRs have been described in the literature, limited information or guidance exists on how these tools can incorporate various activities and topics to be implemented throughout an entire curriculum. The purpose of this report is to describe the curriculum-wide implementation of a simulated EHR software, including the novel learning experiences and costs incurred by the college. Educational activity and settingThe EHR was implemented in various courses across the pharmacy school curriculum in the first, second, and third professional years. FindingsDuring the final year of implementation, the EHR platform was utilized in each of the three didactic years of the pharmacy program. Twenty-two faculty members created cases using the EHR platform. These cases were used across 16 courses and were accessed by students 7191 times during the implementation process. The cost per use of the EHR platform was approximately half that of the most frequently used electronic learning database used in the program. SummaryIn the three years since its inception, the EHR has been highly utilized as evidenced by the overall number of experiences for students, the variety of experiences, and the number of faculty who used the EHR in their course.

Academic Electronic Health Records in Undergraduate Nursing Education: Mixed Methods Pilot Study.

BackgroundTeaching students about electronic health records presents challenges for most nursing programs, primarily because of the limited training opportunities within clinical practice settings. A simulated electronic health record is an experiential, learner-centered strategy that enables students to acquire and apply the informatics knowledge needed for working with electronic records in a safe learning environment before the students have encounters with real patients.ObjectiveThe aim of this study is to provide a preliminary evaluation of the Lippincott DocuCare simulated electronic health record and determine the feasibility issues associated with its implementation.MethodsWe used one-group pretest-posttest, surveys, and focus group interviews with students and instructors to pilot the DocuCare simulated electronic health record within an undergraduate nursing program in Western Canada. Volunteering students worked through 4 case scenarios during a 1-month pilot. Self-reported informatics knowledge and attitudes toward the electronic health record, accuracy of computerized documentation, satisfaction, and students’ and educators’ experiences were examined. Demographic and general information regarding informatics learning was also collected.ResultsAlthough 23 students participated in this study, only 13 completed surveys were included in the analysis. Almost two-thirds of the students indicated their overall understanding of nursing informatics as being fair or inadequate. The two-tailed paired samples t test used to evaluate the impact of DocuCare on students’ self-reported informatics knowledge and attitudes toward the electronic health record revealed a statistically significant difference in the mean score of knowledge before and after using DocuCare (before: mean 2.95, SD 0.58; after: mean 3.83, SD 0.39; t12=5.80, two-tailed; P<.001). There was no statistically significant difference in the mean scores of attitudes toward the electronic health record before and after using DocuCare (before: mean 3.75, SD 0.40; after: mean 3.70, SD 0.34; t12=0.39, two-tailed; P=.70). Students’ documentation scores varied from somewhat accurate to completely accurate; however, performance improved for the majority of students as they progressed from case scenarios 1 to 4. Both the faculty and students were highly satisfied with DocuCare and highly recommended its integration. Focus groups with 7 students and 3 educators revealed multiple themes. The participants shared suggestions regarding the DocuCare product customization and strategies for potential integration in undergraduate nursing programs.ConclusionsThis study demonstrated the feasibility and suitability of the DocuCare program as a tool to enhance students’ learning about informatics and computerized documentation in electronic health records. Recommendations will be made to academic leadership in undergraduate programs on the basis of this study. Furthermore, a controlled evaluation study will be conducted in the future.

Impact of Simulated Electronic Health Records on Informatics Competency of Students in Informatics Course.

ObjectivesNursing has embraced online education to increase its workforce while providing flexible advanced education to nurse professionals. Faculty use virtual simulation and other adaptive learning technologies to enhance learning efficiency and student outcomes in online courses. The purpose of this study was to assess the impact of simulated Electronic Health Records (EHRs) on informatics competency in a graduate online informatics course.MethodsA two-group independent measures study design was adopted to assess students’ perception of a simulated EHR while comparing differences in informatics competencies between an intervention group and a control group. A simulated EHR assignment was provided to students in the intervention group, and a paper assignment was provided to those in the control group. The informatics competency of the students was measured using the Self-Assessment of Informatics Competency Scale for Health Professionals (SICS).ResultsStudents who were enrolled in a family nurse practitioner program in fall of 2019 participated in this study (n = 39). The students expressed positive perceptions of a simulated EHR experience. The SICS results indicated that students in the intervention (simulated EHR) group showed higher informatics competency than those in the control group.ConclusionsThe positive results of this study support incorporating simulated EHR exercises in online courses. Higher informatics competency in the intervention group implies that the use of simulated EHR facilitated learning of complicated informatics concepts.

Using virtual simulation and electronic health records to assess student nurses' documentation and critical thinking skills

IntroductionElectronic health records have become a standard documentation platform to house patient information in most US hospitals. To improve documentation, providers suggest establishing electronic health record user education at the classroom level so students can interact with patient data early. The purpose of this study was to assess student nurses' clinical documentation and critical thinking skills using virtual patients and a simulated electronic health record system. MethodsEighty-four undergraduate nursing students completed assessments on four assigned virtual patients and entered their findings into a simulated electronic health record system. Benner's five stage novice to expert theory was used to evaluate performance of six assessment items. ResultsSignificant differences (p = 0.046) were seen in median scores between the first and second assignments, and between the second and fourth assignments (p = 0.021) with minimal improvements from one assignment to the next. DiscussionData entered in the electronic health record showed that students started at an advance beginner's level and moved to be proficient in documenting basic patient information using critical thinking skills by the end of the first semester. ConclusionIt is important to expose students to electronic health record systems before entering the workforce or while training in a hospital setting to enhance readiness for clinical practice with electronic documentation and critical thinking skills.