1. Anita Showalter, DO, FACOOG (Dist) Associate Dean for Clinical Education Associate Professor and Chief, Women's Health Pacific Northwest University of Health Sciences Medical Students EHR Documentation Training

2. At the end of this module, you will be able to: Describe the role of a scribe in the clinical setting. Demonstrate the difference between entering chart data as a medical student and as a scribe. Describe your plan of taking PNWU students as scribes. To achieve the above objectives, you will learn the following: Suggested Models for Medical Students as Scribes Medical Student and Scribe Policy (Sample) General information for Medical Students as Scribe Student Macros for Medical Student Documentation Scribe Template Video examples and submit a note (medical students only) Learning Objectives and Topics

3. Welcome to the Medical Students EHR 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. What patients need has 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 open 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. Purpose of the EHR Documentation Training

4. For preceptors: This module will help you learn how to incorporate the medical student as a scribe and familiarize you with the policies that should be in place in your institution first. It will also teach you the proper method of signing a scribed note. For students: This module will assist you in learning the role of scribing for your preceptor when requested to do so, and is required for students prior to acting as a scribe. For those who have worked as scribe, this module will help you learn how to combine the roles of medical student and scribe. Purpose of the EHR Documentation Training

5. Model 1: Student sees the patient first then scribes. The medical student sees a patient independently, interviews the patient, and does an examination as directed by the preceptor. 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 (for example, using the One Minute Preceptor model). The physician then does an examination while the medical student acts as scribe. At the end of the encounter, the physician then briefly gives the student feedback to correct errors and teach clinical reasoning. Suggested Models for Medical Students as Scribes

6. Model 2: Physician scribes while student sees the patient. The physician acts as scribe while the medical student conducts the interview and examines the patient. The physician will need to repeat key components of the exam. The physician has an opportunity to observe student interview and examination skills and should follow with feedback and constructive criticism. Suggested Models for Medical Students as Scribes

7. Model 3: Student scribes while observing physician's encounter. The physician interviews and examines patients while the student scribes. This model may be used to orient the student to the practice and the EHR, or used at times to help keep the physician on schedule. The physician should review salient points of each encounter to enhance the student learning experience. Suggested Models for Medical Students as Scribes

8. 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 the medical student as scribe models, the physician may ask the student to perform other tasks that may be helpful in patient care: Deliver patient education Select patient educational handouts Look up research articles Verify drug dosages Check for drug/drug interactions Suggested Models for Medical Students as Scribes

9. Please briefly describe your plan of taking PNWU students as scribes. My Plan

10. Please click the blue link to read a sample Medical Student and Scribe Policy.Medical Student and Scribe Policy When reading the document, you should be able to answer the following question: 1. When can a medical student write a full SOAP note in a patient chart? 2. Who, according to this policy may act as a scribe? Medical Student and Scribe Policy (Sample)

11. Please click the blue link to read the AAMC document - Allowing Medical Student Documentation in the EHRAllowing Medical Student Documentation in the EHR When you read the article, try to answer the following questions: 1.Is using a medical student as a scribe an acceptable practice according to AAMC? 2.What elements is a medical student permitted to document in the chart according to CMS guidelines? General information for Medical Students as Scribe

12. Please click the blue link for the Student Macros for Trainee Documentation when scribing.Student Macros for Trainee Documentation When you read the document, try to answer the following questions: 1. How should a medical student sign a scribed note? 2. How should a physician sign a scribed note? Student Macros for Medical Student Documentation

13. Please click the blue link to access the SOAP Note Template.SOAP Note Template Preceptors: You may refer to this template to guide students. Scribe Template

14. Click one of the following to watch a clinical case. PNWU students are required to submit your own note based on that case. SP Encounter by Dr. DiMeo SP Encounter by Dr. Ramos-Diaz Interview & Exam by Stacy Keach Video examples and submit your own note (For students)

15. Are you able to: Describe the role of a scribe in the clinical setting? Demonstrate the difference between entering chart data as a medical student and as a scribe? Describe your plan of taking PNWU students as scribes? Self-check

16. You've completed this Module. If you have any questions, please contact Dr. Showalter at ashowalter@pnwu.edu.ashowalter@pnwu.edu Thank you! End of Lesson