The following rules apply to student use of electronic medical records at sites where electronic medical records are available:

  1. Students should be able to access electronic medical records using their own personal login information.
  2. Students should be able to enter a full note including history of presenting illness, past medical history (including surgeries, family history, etc.), review of systems, physical exam, laboratory/imaging data, and assessment and plan.
  3. Student notes should become a permanent part of the patient record.
  4. Students should be able to view all patient notes, labs, radiology reports, pathology reports and images.
  5. Students should have the ability to create orders. All student orders must be signed by a resident or attending physician.
  6. A preceptor should be able to view the student’s note and sign it. 
  7. Faculty members must review student notes to ensure accuracy and appropriateness and provide feedback to students.
  8. All required clerkship syllabi must include this policy.