Have students practice logging on and finding key information from a chart.
Students should practice entering past medical history, family history and social history.
Students who appear confident should be encouraged to start note writing for uncomplicated patients. Concentrate on a portion of the note to review for each session, i.e., history of present illness (HOPI) one day and physical exam another.
Med 2
Students should be fairly competent at basic note writing.
Encourage students to start taking some notes during the interview with patient. They’ll need to be reminded of good practices of looking at patient when they’re speaking, avoiding typing during sensitive discussions, and alerting patient if they're looking for specific information and attention is focused on computer and not the patient.
Encourage at least one complete note every other session. Discuss assessment and plan prior to completion.
Med 3
Students should be competent at basic note writing at this point, but some could use refreshers. Encourage students to develop a written plan prior to discussing with you when appropriate for clinic flow. They can addend and change with your direction.
Introduce concepts of templates for acute and chronic conditions and provide information of where to find examples.
Notes should be completed about once per half day as learning occurs through repetition. Utilize the monthlong rotation to assess for improvement.
Med 4
Students should be able to write daily progress notes and history & physical examinations (H&Ps)
Notes should be evaluated daily for accuracy and absence of cut-and-paste from prior notes
Legal Implications
Recall the legal aspects of working with students—student notes can be used for billing if the information is obtained in the presence of the teaching physician or resident. The teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making.
Students cannot function as scribes (i.e. document for you) when they're functioning in a learning capacity.
Your password and account shouldn't be shared and it's illegal for a student to function under your log in as they can complete orders without signature.
