(1) Student documentation is an important part of medical student education.  This documentation should reflect the independent clinical thinking of the student.

(2)  At all sites where students rotate, the importance of learning proper documentation is encouraged.

(3)  Students are encouraged to notify the course director with any problems accessing and documenting in the medical record.

(4)  Students may chart in varied records depending on the site where they are rotating.  They may document their notes in an electronic health record like EPIC or be asked to use a paper chart.

(5)  The use of notes which auto-populate exam findings, assessments and plans is discouraged.  When using templates, or their own prior documentation, students should carefully adjust the note to reflect newly completed work and to ensure the note is a useful addition to the medical record.  It is acceptable to incorporate laboratory or imaging studies.

(6)  Student notes must be co-signed by a resident or faculty member.

(7)  Residents and faculty are encouraged to provide feedback to students on their documentation.  If not provided, students are encouraged to ask for direct feedback on their documentation skills.

(8)  Copying and pasting or otherwise using other’s documentation in paper or electronic form as your own is plagiarism and medical fraud.  This activity will result in a professionalism evaluation in the student’s file.