Medical Students Documenting in the EMR Elizabeth McMurtry, DO, FACEP Assistant Dean for Clinical Education and Faculty Development Pacific Northwest University of Health Sciences

Purpose of the EMR Documentation Training Welcome to the Medical Students EMR Documentation Training Module.   The purpose of the PNWU documentation program is to enhance the medical student experience while preparing the student to better assist the preceptor in the delivery of health care to the patient. Many things in health care have changed over the past decades, and medical education in the clinical setting needs to change to provide relevant opportunities for medical students. In today’s medical practice, most preceptors are on production models.  They would like to teach, but cannot risk having productivity suffer because medical learners are present.  At the same time, computer charting has taken an increasing amount of time.   Patient’s needs have not changed, and medical students have time and expertise to share with them.  Medical students can also assist their preceptors in the delivery of health care to permit more time for the preceptor to teach.  The result should be a rich learning environment where the medical student is learning by doing, and the preceptor’s expertise can be shared without compromising patient care.

New Regulations for Medical Students Documenting in the EMR Effective January 1, 2018: The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any [medical] student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re- perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

PNWU Survey Results

PNWU Survey Results

PNWU Survey Results

PNWU Survey Results

PNWU Survey Results

Suggested Models for Medical Students Documenting in the EMR Model 1: Student sees the patient first then documents.  The medical student sees a patient independently, interviews the patient, does an examination as directed by the preceptor, and documents findings in the student note in the medical record.  The preceptor may see several patients while the student sees the assigned one.  When the preceptor returns, the student gives a brief summary of the interview and exam with the student’s differential diagnosis and plan.  The physician then does an examination while the medical student makes any corrections in the medical record on the basis of the preceptor’s patient assessment.  At the end of the encounter, the physician briefly gives the student feedback to correct errors and teach clinical reasoning. The physician then enters a verification note, stating an independent physical exam was performed, citing active participation in the medical decision making, and confirming (or correcting) the details, findings, and medical decision making points in the student’s note.

Suggested Models for Medical Students Documenting in the EMR Model 2: Physician documents while student sees the patient. The physician documents the physician note, while observing the medical student conduct the interview and examine the patient.  The physician will need to repeat key components of the exam and must personally complete the activities of medical decision making that are used for billing purposes.  The physician has an opportunity to observe the student’s interview and examination skills and can give feedback and constructive criticism. Model 3: Student documents while observing physician's encounter. The physician interviews and examines patients while the student documents.  This model may be used to orient the student to the practice and the EMR, or used at times to help the physician stay on schedule.  The physician should review salient points of each encounter to enhance the student learning experience. 

Suggested Models for Medical Students Documenting in the EMR The ideal rotation experience will involve a combination of models to maximize student learning while having the student assist the physician in documentation and in the delivery of healthcare. In addition to entering H&P documentation into the medical record, the physician may ask the student to perform other computer-oriented tasks helpful in patient care: Deliver patient education Select patient educational handouts Look up research articles Verify drug dosages Check for drug/drug interactions

EPA 5: Document a Clinical Encounter in the Patient Record Provides comprehensive documentation containing important info without unnecessary details or redundancies Documents and interprets osteopathic structural findings and procedure note for OMT Provides documentation including institutionally required elements (e.g. date, time, signature) Creates legible handwritten documentation Enters documentation in a timely manner Communicates in bidirectional manner, soliciting patient preferences, which are recorded in the note Documents clinical reasoning and interpretation of results Engages in help-seeking behavior to fill gaps in knowledge, experience, and skill, enabling development and documentation of management plans Demonstrates general understanding of documentation systems leading to opportunities to engage with others for system improvement Documents one's roles in team care activities

Using EPAs for Developing Feedback Choose a component from EPA 5 to develop feedback about the student’s EMR documentation Was there too much or too little detail? Was there shared decision making documented? Was clinical reasoning and interpretation present and appropriate? Did the student ask for help to develop their documentation and management plan? Develop feedback based on the chosen component ASK what the student thinks went well TELL what you think about what the student describes ASK what the student will do to improve for the next time

Suggested Physician Verification Template The following template is one suggestion for the physician verification note required to complete the student’s documentation: “I performed an independent physical exam, I actively participated in the medical decision making components of this encounter, and I confirm (or correct) the details, findings, and medical decision making points in the student’s note.”

Student Documenting in the EMR This presentation provides preceptors with information about how medical students can participate in utilizing the EMR to enhance patient care. If you have any questions, please contact Dr. McMurtry at emcmurtry@pnwu.edu. Thank you!