FSU-Pensacola

1. Identify what we want our students to be able to do? • Have access to the patient medical record. • Document their patient encounters in patient medical records while on clerkships as well as in E*Value. • Get feedback on their note documentation. • Write a SOAPnote/progress note that meets the USMLE CS-2 requirements, plus accurately and succinctly communicates the visit in such as manner as another physician can take over the patient’s care. • List and utilize major of the aspects of EMR that meets Meaningful Use criteria o Identify the appropriate parts of patient depart process • Identify the ethical issues surrounding the use of templates, copy and paste, so as to honestly and accurately document the systems reviewed and physical exams performed during an encounter • Use the capabilities of an EMR to effectively manage chronic disease • Use technology with patients in a patient centered way that does not detract from the Dr/Patient relationship and communication 2. Identify medico-legal restrictions and guidelines for student documentation • Identify guidelines for medical students documentation in EMRs o Cite CMS’s guidelines for teaching physicians o Cite the recommendations from the AAMC Compliance Officer’s Forum in regards to medical student documentation in the EHR o Recognize the practice guidelines from the ACE (Alliance for Clinical Education) statement on electronic health records • Recognize the need for a student sign-on, and list possible options for providing student access or opportunities to document and get feedback on their documentation. (Excel template) 3. Identify criteria of a good note and use as a guide for providing feedback to students. • Determine optimal frequency of review/feedback to achieve competent documentation during clerkship 4. Identify criteria of proper use of technology with patients and use as a guide for providing feedback to students. References: 1. Compliance Advisory: Electronic Health Records in Academic Health Centers. AAMC Compliance Officers’ Forum 2011; https://www.aamc.org/download/253810/data . 2. Booth N, Robinson P, Kohannejad J. Identification of high-quality consultation practice in primary care: the effects of computer use on doctor-patient rapport. Inform Prim Care. 2004;12(2):75-83. 3. Elliott K, Judd T, McColl G. A student-centred electronic health record system for clinical education. Stud Health Technol Inform. 2011;168:57-64. 4. Gliatto P, Masters P, Karani R. Medical student documentation in the medical record: is it a liability? Mt Sinai J Med. Aug 2009;76(4):357-364. 5. Hammoud MM, Dalymple JL, Christner JG, et al. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24(3):257-266. 6. Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-224. 7. Moser SE, Warren D, Kellerman R. Precepting medical students in the era of EHRs. Fam Med. Feb 2010;42(2):89-90. 8. Schenarts, PJ, Schenarts, KD. Educational impact of the electronic medical record. J Surg Edu. Jan/Feb 2012;69(1):105-112. 9. Stephens MB, Gimbel RW, Pangaro L. Commentary: The RIME/EMR scheme: an educational approach to clinical documentation in electronic medical records. Acad Med. Jan 2011;86(1):11-14. 10. Talwalkar J, Ouellette J. A structured workshop to improve chart documentation among housestaff. MedEdPortal.org: Association of American Medical Colleges; 2009. 11. Yudkowsky R, Galanter W, Jackson R. Students overlook information in the electronic health record. Med Educ. Nov 2010;44(11):1132-1133.