Medical Student Documentation in EPIC System for Efficient Patient Care
Explore the guidelines and best practices for medical student documentation in the EPIC system to ensure professional, accurate, and pertinent notes accessible to all healthcare providers. Learn about history and physical assessments, progress notes, and discharge summaries as key aspects of medical documentation.
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Presentation Transcript
Medical Student Documentation in EPIC Michelle M. Horn, M.D. Associate Professor, Internal Medicine and Pediatrics Medical Student Clerkship Director, Internal Medicine Director of Medical Education, Internal Medicine
Student Note Attending Note Legal Record
Professional Accurate NOTES Appropriate Pertinent
Note Access History and Physicals Progress Notes Discharge Summaries
History and Physical Past History Review of Systems HPI MDM and Assessment and Plan Physical Examination
CMS Changes and UMC Policy Teaching physicians can rely on documentation, by any medical student, of the review of systems and/or past family/social history taken as part of the E/M services. Teaching physicians can rely on the documentation or findings, including history, physical exam and/or medical decision making of a fourth year medical student so long as: Teaching physician personally performs (or re-performs) the physical exam and medical decision making activities of the E/M service being billed; and Teaching physician verifies, based on their assessment of the patient, the accuracy of the fourth year medical student's documentation of the E/M service being billed.
Progress Notes Subjective Objective Assessment Plan
Discharge Summaries Use the Discharge Summary template Cannot be used towards billing by the hospital
