Appropriate medical treatment requires three components: appropriate physical assessment, appropriate medical intervention and appropriate medical records. Health information management (HIM) training involves learning to update patient medical records (charts). Clinicians generally update charts during patient consultations; opportunities to practise charting outside that setting are rare. In a previous training program, students watched a patient consultation video; then, practised charting. However, this was ineffective because students were ‘just writing’ and could not effectively practise charting. Our objective is to design a new HIM training program, where students can chart patient information during consultation, using a patient simulator and electric medical record (EMR) system.

Our HIM training program addressed the third aforementioned treatment requirement. Our training room had an EMR system and patient simulator (SIMMAN 3G). In the training simulation, students assessed, treated, and updated the chart of a simulated patient: 78-year-old man with suspected pneumonia. Students listened to the chief complaints, assessed the physical signs, and charted relevant data.