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.