Authors

  1. Sanchez, Colleen MSN, RN

Article Content

Using an academic electronic health record (EHR) web-based program in the clinical setting allows students to practice documenting in a simulated patient's chart without the risk of documenting in the legal medical record. The EHR simulator software is web based, allowing access anywhere the Internet is available. Access to this software can be done on the computers at the clinical facility, if allowed, or any other device that students bring to the clinical site, such as a tablet or phone. Instead of logging into the facility's EHR, students log into the EHR simulator, either on the computer at the nurses' station or the device they bring, and chart real-time head-to-toe assessments. Students are expected to demonstrate their understanding of their patient's clinical problems by completing a clinical packet assignment, which includes patient diagnoses, history, pathophysiology, medications, head-to-toe assessments, nursing care plans, and a cultural/psychosocial/spiritual assessment. Once students are ready to document the patient's assessment, they log into the academic EHR program, create a new patient, and document their findings. To avoid HIPAA violations, I have students use their name for the patient but other information pertains to the patient. If time permits, students can start this assignment in the clinical setting, minimizing homework. Clinical instructors can grade the documentation anywhere Internet access is available. Because many hospitals deny student access to document electronically, EHR simulator software permits students to document in real-time practicing realistic charting.