Medical Student Documentation Policy
Purpose
The School is committed to provide experiences for student learning and growth in the clinical environment. The purpose of this policy is to provide mechanisms and procedures for students to document in the medical record.
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 colleagues and 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.
Principles
- To be able to practice effectively as a clinician, students must learn the skill of communicating effectively in the medical record.
- 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.
- The medical student note is a part of the medical record whether used for billing purposes or not. These notes are a product of student work.
- Clinical experiences occur at a number of different sites and specialties; institutions and individual services and practices may have different expectations and/or standards of what students are able to do.
Policy
The following describes the expectations of students, residents, attendings, and clinical rotation directors.
Students
- Students will document significant patient encounters defined as those for which they are the patient’s primary provider including admission, progress, procedure and outpatient notes.
- In general, students will document at least 2 patients/session in the outpatient setting and at least 1 patient/day in the inpatient setting for core clerkships, and will often document more frequently during fourth-year clinical rotations.
- Students may use clerkship/elective approved templates that are designed to facilitate the documentation process while still promoting student learning of fundamental documentation skills and clinical reasoning.
- If the note is used for billing (i.e., needs an attending’s attestation), students will route their notes to their supervising resident or attending for attestation, with the process depending on the clerkship/elective.
- Based on feedback received, students will make corrections as appropriate in their documentation.
Residents/Attendings
- Residents and/or Attendings will complete notes on patients seen by medical students. The workflow to complete the notes will depend on the clinical rotation.
- Residents and/or Attendings will provide feedback to students on their documentation, and may use the Bridges Brief Observation Tool (BBOT) to do so.
- Residents and/or Attendings will ensure patient information is correct in their own documentation and are responsible for the content of the student note if the content is attested.
F2 and Career Launch Rotation Directors
- Rotation directors or their designee 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.
- Rotation directors will clarify individual rotation expectations on notes (e.g. minimum number, note type, whether on every patient, etc.) on CLE and at orientation.
- Individual rotation directors may adapt expectations for medical student documentation as appropriate to optimize learning in specific clinical environments or sites.
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 them into the EHR or to have them write notes or accomplish other tasks while someone else is logged in.
Procedure
Site Specific Electronic Health Record (EHR) Stipulations
UC Health: In the ambulatory and inpatient settings, under certain circumstances, medical student notes can be attested by an attending and used as a visit note for billing purposes. The preferred workflow is determined by the specific clinical service and rotation.
- For student notes that are used for billing: These notes must be attested by an attending. Medical students must have their notes reviewed by residents/fellows prior to attending attestation or sent directly to the attending for review. If sent to the resident, the resident may edit the medical student note that will be attested by the attending. A physician (resident or attending) must be physically present with the medical student (exceptions for ROS/PSFHx). Attendings must perform their own physical examination. Best practice is for notes to be completed and encounters closed within 2 days of an ambulatory visit and the same day as an inpatient service.
- For notes that are only for students’ educational purposes (not for billing): These notes may include a disclaimer that they are to be used for educational purposes only, and not to be relied upon or used for patient care. These standalone notes are not co-signed by a supervising physician. The decision to have a disclaimer, e.g., as a smartphrase, is made by the specific service and rotation. A sample disclaimer:
This Student Note is only for the student’s educational purpose. The contents of this note have NOT been reviewed by a supervising physician, and should NOT be utilized for care and management of this patient.
ZSG: 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 may document services in the electronic medical record. The responsible physician attending must verify any student findings, be identified as a co-signer and must provide an addendum to the student note or an additional free standing note.. The responsible physician attending must personally perform (or re-perform) the physical exam and medical decision-making activities of the service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work. Physician residents may be added as an additional signer and provide contributions to the medical student documentation that need to be verified by the attending physician.
Accountable Dean or Director
Associate Dean for Curriculum
Related Policies
Clinical Supervision of Medical Students
Medical Student Work Policy
Approval Date and Governing Body
- CCEP
- Career Launch 2022 (policy discussed at April 2022 Career Launch meeting]
- Foundations 2 2022 (new billing discussed November 2021 F2]
