University of California San Francisco
UCSF School of Medicine UCSF Medical Center

UCSF Medical Center and SOM Medical Student Documentation Policy

Overview

Documentation in the medical record is a necessary activity of patient care. The ability to document appropriately is an essential physician skill for providing quality care. The ACGME states that residents are expected to maintain comprehensive medical records; the LCME states that the medical school curriculum must include specific instructions in communication skills related to physician responsibilities including communication with other health professionals. The UCSF School of Medicine MD Competencies and Milestones include competency expectations for all students in the use of information technology and medical records.

In addition to allowing students to develop this essential written communication skill, the practice of documenting patient encounters also allows students to 1) more fully participate in patient care, 2) organize their thinking related to patient problems, and 3) demonstrate their clinical reasoning. Therefore, students must have opportunities to learn and have enough practice to achieve expected competency levels for documenting the following in the medical record (whether on paper or in an EHR): admission, progress, procedure, and outpatient notes. Individual clerkships may adapt expectations for medical student documentation as appropriate to optimize learning in specific clinical environments or sites.

Though not used in billing, the medical student note is a part of the medical record. These notes are a product of student work and may not be assumed by a resident or attending as a resident or attending note, respectively.

Policy

The following are expectations of students, residents, attendings, and clerkships:

Students

  • Will document significant patient encounters defined as those for which they are the patient’s primary provider. This may not necessarily include every clinical encounter a student experiences.
  • At minimum, will generally document at least 2 patients/session in the outpatient setting and 1 patient/day in the inpatient setting for core clerkships (unless fewer patients were seen), and will often document more frequently during fourth year clinical rotations.
  • Will complete their documentation in EHR without the use of templates or using only clerkship/elective approved templates. Students may not use self- or resident-generated templates. Clerkship/elective approved templates are designed to facilitate the documentation process while still promoting student learning of fundamental documentation skills and clinical reasoning.
  • Will route their notes to their supervising resident or attending for feedback
  • Based on feedback received, will make corrections as appropriate in their documentation with addendums to their original note.

Residents/Attendings

  • Will complete their own documentation on patients seen by medical students. They will not “take over” or copy a student’s documentation verbatim as their own.
  • Will provide feedback to students on their documentation, and may use the Brief Structured Note Review (BSNR) form to do so.
  • Will ensure patient information is correct in their own documentation, not relying on the student note which might have missing or inaccurate information.

Clerkships

  • Will orient students to how their documentation will be used, so students understand how their documentation efforts contribute to patient care and are a part of the legal medical record.
  • Will clarify individual clerkship expectations on notes (e.g. minimum number, what type, whether on every patient, etc) on CLE and at orientation.

Site Specific Electronic Health Record (EHR) Stipulations

Parnassus:  Medical student notes are finalized by students as stand-alone notes in the medical record and are NOT pended or sent to others for co-signature. Instead, the notes are to be cc’d to supervising residents or attendings for feedback purposes only. Corrections to the student note are to be made by the student using an addendum.

SFGH:        Medical student notes are written in a separate section from the resident or attending notes and include a medical student disclaimer statement. Completed notes are assigned to the supervising resident or attending for review, feedback, and co-signature.

VA:            Medical students notes are forwarded to the supervising intern/resident for co-signature.

EHR Professionalism Standards

It is a violation of UCSF rules, federal regulations, state licensing laws, and the security features of the electronic health record systems as well as a risk to patient safety for anyone to use someone else’s login to sign into the EHR and document or accomplish tasks under someone else’s name. Everyone must use their own login. No one may offer to sign someone else into the EHR with their login. No one should accept anyone’s offer to sign him/her into the EHR or to have him/her write notes or accomplish other tasks while someone else is logged in.

References

  • Hammoud et al. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med 2004;24(3):257-266.

Approved April 1, 2013 by these governing bodies:

UCSF School of Medicine Clinical Core Operations Committee (CCOC)

UCSF School of Medicine Integrated Curriculum Steering Committee (ICSC)

UCSF Medical Center APeX Documentation Working Group

UCSF Office of Ethics and Compliance, Clinical Enterprise Compliance Program