Documentation in the Electronic Health Record (EHR)

Writing Patient Care Orders

Michigan Medicine uses MiChart (an EHR) with an online order entry system. The policies and procedures as they relate to medical students writing patient care orders are:

1. Students may write patient care orders at the direction of the attending physician or primary House Officer of the patient.
2. These orders shall be electronically co-signed by a physician prior to being carried out.
3. The student has the primary responsibility for securing a timely co-signature by a primary physician involved in the care of the patient.

Student Notes

As of Jan. 2, 2019, the Centers for Medicare and Medicaid Services changed their policy and allows medical student documentation to be used for billing purposes for evaluation and management (E&M) activities in both the inpatient and outpatient setting. Students are allowed to write both admission and progress note types. Faculty must attest and there are two attestations that will be added: one for notes written by a student and one for notes written by a student and a house officer. Faculty are still required to personally examine the patient and participate in medical decision making.