Student Notes for
M3s and M4s
General Information

At University of Michigan Medical Center:

The FGP Board recently approved a new policy on medical student documentation in patient records for billing purposes. Effective May 12, 2008, medical students may NOT be used as scribes. To accommodate this change, the medical student "Scribe" template in CareWeb has been removed and new generic med student templates are available in “Create Doc” in CareWeb.

Summary of the policy:

• Medical students will continue to write notes to the medical record.
• Medical students may not serve as “scribes”.
• Faculty or House Officers must perform and document their own HPI, exam and evaluation and management of the patient.
• Faculty or House Officers may refer to ROS and PMFSH from the student.
• Faculty should provide feedback to medical students and edit medical student notes as needed.

As a result, processes for using CareWeb Create Doc will change for medical students as well as the Faculty and House Officers.



At the VA: No change in policy

Students are allowed to scribe notes for their team.

 

Resources

Medical Student Documentation Instructions - 05.02.08
Dr. Grum's Presentation to the M4 Students - 04.25.08
VA Guidelines