Proposed Management Guidelines and Rules for Electronic Medical Recording Systems for Clinical Clerkships: Report of the 14th Workshop of Medical Education on Electronic Medical Recording Systems for Clinical Clerkships / 医学教育

Medical recording is an important learning issue for the clerkship curriculum. Privacy laws require that medical students' access to patient information be managed by faculty members. The Workshop of Medical Education was convened at the Medical Education Development Center, Gifu University, in October 2004 to discuss the management of electronic medical recording systems for clinical clerkships. The purpose of this article is to propose management guidelines and rules for electronic medical recording systems for clinical clerkships in Japan.

Usefulness of electronic medical record system for clinical clerkship / 医学教育

We compared the effects on clinical clerkships of an electronic medical record (EMR) system and a standard medical record system. Using an EMR system, students described medical records with a problem-oriented medical record system/subject objective assessment, and plan that was much better than the standard medical record system. In the EMR system, students cannot see physicians' medical records, including laboratory data and X-ray films. Instead, students themselves must obtain the patient history and request examinations as physicians do. This system helps supervisors give suitable comments and provide data that students have requested. Directors can also evaluate supervisors by reviewing their comments. Therefore, an EMR system has the advantage of problem-oriented medical record system-based learning for students and is also useful for clinical clerkships.