Student Provider Electronic Medical Record Documentation

     

4.1.1 Student Providers are defined as medical students, physician’s assistant students, and advanced practice nursing students who are rotating through USA clinical services for educational purposes.

 

4.2.1 Student Providers will be allowed to document in the Electronic Medical Record (EMR) in one of two ways:

4.2.1.1 Student providers may create notes that are primarily educational in nature, which will fall under the Note Type of “Student Provider Note” as cataloged in the Cerner EMR.

4.2.1.2 Student providers may function as scribes for their supervising licensed providers.  The supervising provider will be the author of record for the note, which will be cataloged in the Cerner EMR by the type of note created (e.g., Internal Medicine Progress Note, Pediatrics Office Clinic Note, History and Physical, etc.).  The explicit goal of this method is to provide the most meaningful educational experience possible for the student provider in clinical settings where the Student Provider Note method would less-effectively facilitate this experience.

4.2.2 Student providers will be instructed at the beginning of each clinical rotation which method is to be employed, or if this decision will be left up to each supervising provider.  The Student Provider Note method will be the default unless the student provider is explicitly instructed to utilize the Student Provider As Scribe method.

 

4.3.1 The Student provider selects the Cerner EMR Note Type of “Student Provider Note” when creating the note.  A complete note appropriate for the setting may be created, e.g., office visit note, history and physical, consult note, etc.

4.3.2 As the student provider signs the note, no attestation statement is required.  The note is submitted to the supervising provider for educational review as part of the signing process.

4.3.2 Student Provider Notes are considered educational in nature, and thus not part of the official medical record, with this exception:  The billing provider for the encounter, generally the attending physician or a supervising midlevel provider, may reference the student provider’s review of systems and past family/social/medical history, using this attestation in the EMR, or similar attestation as amended under USA Health rules and regulations:

4.3.2.1 I have reviewed the student provider's documentation of the review of systems and past, family, and social histories. I have performed and documented all other elements of the service.  See my separate note, with any exceptions and/or additions I have made to the student-documented elements.

4.3.2.2 If this statement is employed, those parts of the student provider’s note become part of the official medical record.

4.3.3 This method of documentation is expected to be the norm in clinical settings that include student providers, residents, and attendings.  The student provider will create an educational Student Provider Note that will not be referenced by the resident’s note.  The resident’s note will be cosigned by the attending in an appropriate manner to constitute the official medical record and billable document.

4.3.4 All student providers are allowed to use this method.

 

4.4.1 Student provider selects the Cerner EMR Note Type pertinent to the clinical setting, as instructed by the supervising provider.

4.4.2 The student provider may participate in the gathering and entering into the EMR of structured data elements—past medical history including medication and allergy lists, social history, and family history.

4.4.3 The student provider may assist the supervising provider in the navigation of the EMR and the location and retrieval of information.

4.4.4 The student provider may only enter History of Present Illness, Physical Exam, Assessment, and Plan in the presence of and at the expressed direction of the supervising provider.

4.4.5 The student provider functioning as scribe will apply this attestation in the EMR, or similar attestation as amended under USA Health rules and regulations, as the document is submitted to the supervising provider:

4.4.5.1 I am recording for, and in the presence of, Dr. (INSERT PROVIDER NAME).

4.4.6 After review and completion of this document, the supervising provider will apply this attending attestation in the EMR, or similar attestation as amended under USA Health rules and regulations:

4.4.6.1 The documentation recorded herein accurately and completely reflects the services I personally performed and the decisions made by me, in compliance with regulatory requirements.

4.4.7 The supervising provider will be an attending, or a midlevel provider functioning as a clinical instructor per the clinical rotation’s established practice.  A resident MAY NOT utilize a student provider as a scribe; residents are expected to create their own original documentation.

4.4.8 First and second year medical students are not allowed to use this method of documentation; they must use the Student Provider Note method.

 

 

4.5.1 These policies will be made known to all supervising providers, student providers, and clinical venues, and will be taught during EMR training.