Documenting Electronic Medical Records

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IUSM-PO-EDU-CUR-0018

Full Policy Contents

Scope
Policy Statement
Reason for Policy
Procedures
Definitions
Sanctions

ADDITIONAL DETAILS
Additional Contacts
Related Information
History

Effective: 11/29/2016
Last Updated: 01/27/2017

Responsible University Office:
Office of Academic Records and Promotion

Responsible University Administrator
Assistant dean for academic records and promotion

Policy Contact:
Assistant dean for academic records and promotion

RESPONSIBLE Course/clerkship directors
ACCOUNTABLE Senior associate dean for medical student education
SUPPORT Assistant dean for academic records and promotion
CONSULT Competency directors
INFORM Reporting faculty member, involved student

LCME Standards

3.5 Learning Environment/Professionalism


Scope

All students enrolled in the Indiana University School of Medicine. All faculty and residents should understand this expectation of students.


Policy Statement

All students must use their own words to document their interactions with patients in the electronic medical record.


Reason for Policy

To provide direction for maximal educational experience in patient care as it relates to electronic medical record (EMR) documentation. In addition, ethical and legal considerations should be documented.

Students must use forethought before documenting in the electronic medical records their encounters with patients. The IUSM encourages independent thinking as a way to develop professional skills, including communication and problem solving. Electronic medical record systems enable the repeated use of stored material by “copying” and “cutting and pasting” but the educational value of documenting medical records may be reduced if students do so. The use of others’ words in the EMR also has other associated issues (such as legal liability). These should be distinguished from the educational goal.


Approval

Approved by the Curriculum Council Steering Committee 11/29/2016.


Procedures

  1. All IUSM medical students must document patient encounters in their own words without solely “copying,” “cutting” or “pasting” from the previous medical record. When documenting patient contacts for the same patient in serial fashion, each record will be developed from the clinical encounter and not the previous record.
  2. If there is any other situation in which use of others’ words is being considered, the student should consult the clinical preceptor about the appropriateness of citation. Proper citation of sources is necessary and the student is referred to policies regarding citation and plagiarism covered elsewhere.

Definitions

Plagiarism: Plagiarism is the act of representing someone else’s words or ideas as one’s own. It may be intentional (e.g., copying or buying another’s paper online) or unintentional (not giving credit for an author’s ideas that one has summarized in his/her own words).

Data entry: Each person who makes an entry into the EMR accepts responsibility for the information contained in that entry. Patient data are protected under HIPAA.


Sanctions

A student who fails to abide by this policy may be referred to the Student Promotions Committee.


Additional Contacts

Subject Contact Phone Email
Medical Student Education Kim Sandrick (317) 274-1970 ksandric@iu.edu

Related Information

Professionalism Competency policy
Academic Policies and Professional Standards policy
Satisfactory with Concerns policy


History

Approved by the Curriculum Council Steering Committee 09/11/2012
Revision approved by Curriculum Council Steering Committee 11/29/2016
Reviewed and re-approved by the Curriculum Council Steering Committee 01/27/2017

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