Documentation
Authorized students may make notes in the medical record by written or computerized format with electronic signature at time of entry; notes via dictation are not allowed except in designated AI assisted clinical activities. These must be reviewed manually to ensure only pertinent and accurate data has been recorded to prevent misleading output and resulting future errors. Students shall never log into the electronic medical record (Epic) under their personal employee credentials for any reason. Students shall never log into Epic under any clinical rotation supervisor’s or other clinical staff’s credentials for any reason. All notes must be reviewed by the clinical rotation supervisor at the time of the entry and before the end of shift. Notes will be signed with student name and title (PT Student, RN Student, etc.) and cosigned by the rotation supervisor. (The supervising staff individual must write their own note for the patient.) In order to secure Epic access, students from applicable programs should monitor their inbox for an email from ISProvisioning 1-2 weeks prior to the start of rotation and follow all instructions outlined therein, including but not limited to: How to create and register a personal password to replace the temporary password initially supplied in the email body. This password is to remain private to the student. How to access and complete all assignments/assessments located in the Workday Learn system. After completion of training, allow up to 3 business days for access to take effect. If assistance is needed after receipt of ISProvisioning email, students should contact the IS Help Desk at 504-842-3610. To write a note for co-signature within Epic:
Locate and enter the "Create Notes" section. Locate and select the “Med Student” tab. Create new note under med student tab. From here, you can cosign to preceptor.
Student Medication Administration Record (MAR) and clinical flowsheet documentation must be cosigned by the clinical rotation supervisor. Students are responsible for entering the appropriate cosigner’s name in the cosign field. Medication Charges are automatically entered when medication administration is documented on the MAR by the student. Clinical flowsheet documentation must be cosigned by the patient’s Staff Nurse. Note: OMC West Campus Skilled Nursing Facility (SNF) - Only the School Instructor will have access to cosign both student clinical flowsheet and MAR documentation.
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