Abstract:

The Hospital Universitario San Ignacio (HUSI) linked to the Pontificia Universidad Javeriana in Bogotá, Colombia is the setting for clinical practice for the University Medical School where over 300 undergraduate medical students make clinical rotations/clerkships, between the 5th and 10th semesters. Some of the most important skills for the student to achieve are: to perform diagnostic procedures, treatment and rehabilitation of the disease, to make rational use of resources and to critically evaluate their impact on society. In order to do so, it is fundamental to register and review all the relevant clinical information obtained from the patient to perform the initial history or clinical evolution. Here the information is analyzed once a diagnosis is defined and assumes decisions to issue a diagnostic or therapeutic conduct to follow in each patient.

The daily management of the HUSI Electronic Medical Record (EMR) uses a hospital information system online, which is fully virtualized, named Integrated Hospital Management System SAHI ©. SAHI is a software solution that has 18 modules and 3 links; it is designed by Colombian suppliers on a single data model articulated by a SQL server engine. The management information system`s attention and registration times as well as the strict system of passwords and auditing, limited undergraduate`s participation. It also implied a parallel process in which they had to keep a didactic medical record in personal files or join residents and teachers in order to keep record of the patient`s clinical record in the EMR system (SAHI).

In order to improve the weakness generated in the education of our students, we designed a parallel information system that allows the undergraduate students to operate with its own username and have access to it from a PC, laptop or tablet. This system receives real-time updated information of the student`s patients. The student can autonomously and creatively generate the proper notes and take the decisions deemed appropriate for the patients according to their clinical status and evolution. These notes are kept in this parallel academic system which must be revised by the teacher or by the supervising physician who evaluates through a preset format of evolution. When the supervisor approves that the student`s note is correct, using a special password, he authorizes the update and the evolution becomes an official EMR for the patient. This also allows improving the learning process, overcoming the weaknesses raised, recognizing the good work of students and reducing the time monitoring and filling out medical history in an academic process.

Keywords:

Academic training system, Medical Education, EMR.