LAUSR

This pre- and poststudy included Internal Medicine interns at a community-based hospital. Interns were provided an electronic medical record pocket guide to assess for any improvement in information gathering during patient care and whether their confidence level improved. The authors’ results show that use of the electronic medical record guide was well received among Internal Medicine interns and that it led to increased completeness in patient information gathering. 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%, P < 0.001) and in intern confidence (P = 0.001). 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.