Guidelines For Clinical Activities

• ROLES AND RESPONSIBILITIES OF MEDICAL STUDENTS

  1. IDENTIFICATION

     It is essential that SIU students be immediately recognizable as medical students to patients, house staff members, and staff of both hospitals.

     In accordance with the School of Medicine directive, you are expected to wear the standard short white coat and identification badge with the SIU logo.

     During your clinical work, you will be introduced to patients as medical students. This term should not be augmented by modifying statements such as “student physician” or “student doctor.”

  2. PATIENT CARE PROCEDURES

     After appropriate instruction and demonstration of necessary skill, you may perform only routine venipuncture without supervision. All other patient care procedures (e.g., lumbar puncture, suture removal) may be performed by you only if:

     • you are directly supervised by a resident or attending physician who is present during the procedure;

       OR

     • you have obtained prior approval of a resident or attending physician who has communicated his approval to the nurse in charge.  The nurse in charge is instructed to ascertain that such approval exists.

     At St. John’s Hospital, in the absence of an attending physician or resident, the primary responsibility for managing an emergency obstetrical delivery rests with the labor room nurse.  Also at St. John’s, a protocol exists for student participation in the Intensive Care Unit which is accorded students during their rotation through the area.

     You may decline to perform any patient care procedure requested by a resident or attending physician for which you believe you have not received necessary instruction or have not acquired the necessary skill.  Any student who declines to perform a requested patient care procedure should notify the chief resident of the service immediately.

  3. PROCEDURES FOR ROUTINE PATIENT EXAMS

     Insofar as possible, medical students should do the history and physical examination of patients to which they have been assigned, in the respective patient’s room.  Adequate floor nursing personnel will be available to assist you when examining female patients.

     Memorial:  Examining rooms can be utilized on the floors which have them.  Examining tables with stirrups (suitable for pelvic examinations) are available for use on most, but not all, hospital floors. You may contact personnel at the nursing stations for this information.

• HOSPITAL MEDICAL RECORDS

  • PRIOR MEDICAL RECORDS

    Prior medical records of a patient assigned to the SIU Teaching Service are requested by nursing personnel on admission of that patient to the unit. These charts are kept at the nursing station during the patient’s stay in the hospital for ready access to medical students.  The charts must not be removed from the floor to which the patient has been assigned. Psychiatric and Chemical Substance Abuse Records are subject to legislative confidentiality rules.

  • STUDENT ACCESS TO MEDICAL RECORDS

  Generally, only hospital staff have access to medical records; however, students involved in health services research, under appropriate supervision of a faculty member, may study these records on the premise.  Appropriate lead time is appreciated by the Medical Records Department for student projects requiring a substantial number of records.

  • MEDICAL RECORD ETIQUETTE

  The medical chart is a legal document upon which significant lawsuits revolve. To make the document as useful as possible, all the entries should be in black ink, dated, timed, and signed.  Deletions should be done with a single line, initialed and dated. No part of the chart is to be removed. Keeping in mind that one might be asked to discuss chart entries in court, one should avoid sarcasm, disparaging remarks about the patient, or the other services involved (chart wars), and speculation as to what would have happened “if only.”  Speculation as to what would have occurred with other treatments, etc. adds nothing to the present care and clouds the issues.

  • REQUESTS FOR INFORMATION

    No person caring for a patient has the right to divulge information regarding that patient without specific permission to do so.  You are not to converse with or provide written material regarding medical records for friends or relatives, representatives from the news media or law enforcement divisions, etc., without prior consent of the hospital administration.  In all probability, the party requesting information should be referred to the patient’s attending physician, or to the patient himself.  At times, the Public Relations Department of both hospitals directs release of information.

  • PATIENT’S HISTORY AND PHYSICAL EXAMINATION

    Students are expected to write medical histories and perform complete physical examinations on the patients assigned to them by clinical instructors. Notations on the patients’ charts should be in standard SOAP format, which conforms to accrediting body requirements.

    The history should be a record of the information provided by the patient or his or her agent. In addition to a concise statement of the patient’s chief complaint, the record should show the details of the present illness, inventory of systems, past history, social history, and family history.  Information from the history and physical examination must be on the chart within 24 hours after the patient’s admission.

  • PROGRESS NOTES

    Progress notes written by students should present a pertinent, chronological report of the patient’s condition and the results of treatment.  Information concerning operative or other miscellaneous procedures performed may be entered in the usual progress note sheet.  These notes become a part of the hospital record.

  • DIAGNOSTIC AND THERAPEUTIC ORDERS

    Students may write orders only after consulting with the attending physician and/or with the appropriate house staff member(s) assigned to the patient in question.  These orders may be implemented by nursing staff as follows:

    A student writes orders and obtains the attending physician’s or appropriate house staff member’s personal countersignature, if these physicians are available. Nursing personnel then carry out the orders as personally countersigned.

    It is the responsibility of the student who writes the order to contact either the attending physician or the appropriate house staff member via telephone from the nursing station to discuss the orders and then offer the nurse the telephone for confirmation or further interpretation of the written orders to assure authenticity and appropriateness. The nurse then notes on the chart that telephone approval of the orders was obtained. The appropriate resident or attending physician initials the orders at the next hospital visit, just as other telephone orders are handled.

    You should not expect or allow orders to be carried out unless they are properly authorized.

  • MEDICAL STUDENT’S SIGNATURE

  All chart entries (histories, physical examinations, progress notes, orders, etc.) must be signed. These signatures include name and year of training.  An example of the format to be used is as follows:

  David Jones, SIU MS III (or MS IV)

  When a nurse makes the entry on the chart, citing that a student has visited a patient, the entry should likewise include the student’s name and year of training.

  • INCLUSION OF INFORMATION ON PERMANENT RECORDS

  If the medical history and record of physical examination performed by the student are adequate and are countersigned by the attending physician, they are accepted as part of the permanent record. If the history and physical have not been countersigned, they are forwarded to the attending physician, who will then be responsible for recording a history and physical.

  (St. John’s Hospital provides students with a special history form with a color-coded bar to distinguish it from other history forms.)

  • STUDENT DICTATION

  Year four students may dictate in SIU Clinics and both hospitals, as outlined below.

  At St. John’s Hospital, year four students may use the dictaphone dictating system to dictate history and physical and clinical summaries during their electives.  Students are required to receive training by the medical school and by the St. John’s Hospital Medical Records Department regarding the process of dictation and the medicolegal nature of the patient’s medical record and in particular the pertinent data to be included.  Instruction may be received from Medical Records Department at any time during their regular hours.  This is a requirement prior to year four students initiating dictation.

  At Memorial Medical Center, year four students may dictate appropriate portions of clinical records at MMC during electives, using hospital dictating equipment and transcribing services. Students are required to receive training regarding the various types of dictating equipment prior to the first dictation. The ten-minute training session can be arranged in the Department of Medical Records during regular business hours.

  Only year four students have dictation privileges.

• STATEMENT OF PATIENT CONFIDENTIALITY

  It is to be clearly understood that privacy is a basic right of every patient treated in programs or facilities of the School of Medicine. This statement is to certify my agreement and understanding of the patient confidentiality I am expected to observe as member of the faculty, staff, or student body of Southern Illinois University School of Medicine.

  Section 3 of the Medical Patient Rights Act (410 ILCS 50/1 et seq.) prohibits disclosure of the nature or details of services provided to patients, except to (1) the patient, (2) the party making treatment decisions if the patient is incapable of making such decisions, (3) those parties directly involved with providing treatment to the patient or processing payment for that treatment, (4) those parties responsible for peer review, utilization review and quality assurance, or (5) as otherwise authorized or required by law.  Consistent with this statute, I agree as follows:

  Handling of Patient Records

  Except as permitted by Illinois law, I will not release information pertaining to a patient unless specifically authorized to do so by the patient or the patient=s legal representative. I understand that patient files, medical records, medical transcription, and patient accounts (in paper or electronic form) are not to be carried, transferred, or disseminated outside the School of Medicine without specific authorization. This includes individually-identifiable information gathered for research or other scholarly purposes. Furthermore, I recognize that failure to control access to confidential patient information (in paper, electronic, or other form) for which I am responsible is equivalent to unauthorized transfer.

  Disclosure of Patient Information

  Discussion or other disclosure of any information regarding a patient=s medical, financial, or personal data for reasons other than the discharge of my assigned duties is inappropriate. Therefore, I will limit my discussion of any particular case to those parties with whom I must interact to assure the successful fulfillment of my duty to the patient.

  Other Professional Conduct

  Unless authorized or required to do so, I will not provide a diagnosis, discuss the mode of care, draw any conclusions concerning a patient’s health and welfare, or provide an impression or interpretation of any medical data to the patient or to any other party.

  I have read and understood the above statement.  I further understand that violation of this statement constitutes a serious breach of professional ethics and may result in disciplinary action, including termination of employment or dismissal of students from the School of Medicine.

  Approved by the Executive Committee, 3/16/98

• AAMC STATEMENT ON PROFESSIONAL RESPONSIBILITY IN TREATING AIDS PATIENTS

  The acquired immunodeficiency syndrome (AIDS) has had an impact on the medical profession far beyond its pathophysiology. All fields of clinical practice have been dramatically altered by this disease.  It has posed a significant challenge to the nation’s health care system in providing for both the financing and delivery of care to those afflicted.  Moreover, this epidemic, which is unparalleled in the latter half of the twentieth century, has confronted the medical profession with numerous moral and ethical issues.  A central concern, to which this statement is directed, is the physician’s responsibility to provide care to all patients.

  The Association of American Medical Colleges (AAMC) has taken special note of the fears and concerns of medical professionals and those in training regarding the care of patients infected with the human immunodeficiency virus (HIV).  Data indicate that a physician’s occupational risk of acquiring HIV infection is small. However, because of the lethal nature of the disease, many physicians are concerned about transmission of infection, especially in settings where invasive procedures are performed such as the operating room or cardiac catheterization laboratory.

  Personal risk to the physician in the practice of medicine is not a new phenomenon even within this century, as the history of tuberculosis, poliomyelitis, influenza, and syphilis demonstrates.  But scientific advances, especially the development of vaccines and antibiotics, have tended to lower consciousness of these continuing risks for an entire generation of younger physicians, medical students and residents.  AIDS has brought this consciousness once again to the fore.

  The AAMC’s special concern is with those medical students and residents, now and in the future, whose preparation for entry into the profession is the responsibility of medical school faculties. Medical education cannot be narrowly conceived as simply the imparting of knowledge and skills.  It has as its objective the development of professional men and women who are prepared to adhere to the highest standards of conduct and behavior asked of few members of our society.  Entry into the medical profession is a privilege offered to those who are prepared for a lifetime of service to the ill.

  The HIV epidemic must serve to remind us of these basic principles and the fundamental responsibilities of those who aspire to the practice of medicine and those charged with preparing them for it:

  • Medical students, residents, and faculty have a fundamental responsibility to provide care to all patients assigned to them, regardless of diagnosis.  A failure to accept this responsibility violates a basic tenet of the medical profession—to place the patient’s interest and welfare first.
  • Faculty members have a special responsibility to model the professional behavior and attitudes expected of physicians in training in their own willingness to provide competent, sensitive, and compassionate care to all patients.
  • Each medical school and teaching hospital must accept the responsibility to help medical students, residents, and faculty address and cope with their fears and prejudices in treating HIVinfected patients. This responsibility includes providing the following:
    • an accurate portrayal to medical school applicants of the personal risks involved in medical practice;
    • uptodate information on the modes and risk of transmission of the virus;
    • training in protective measures to be employed in the clinical setting, monitoring compliance with them, and defining procedures to be followed in the event of potential exposure;
    • appropriate facilities, equipment, and personnel to avoid unnecessary risk;
    • counseling to those who continue to express reluctance to participate in education and patient care programs with HIV-infected individuals.

  Further, each medical school and teaching hospital should articulate a clear policy emphasizing the physician’s responsibility to provide care to patients without regard to the nature of their illness.

• ILLINOIS DOMESTIC VIOLENCE ACT:  NOTIFICATION OF DUTY TO DISCLOSE

  As a medical student at Southern Illinois University School of Medicine, you are subject to the informational disclosure requirement contained in 401 of the Illinois Domestic Violence Act (750 ILCS 60/101 et seq.).  This means that you are required to offer to a person suspected to be a victim of abuse immediate and adequate information regarding services available to victims of abuse.

  "Abuse" for purposes of the Domestic Violence Act means physical abuse, harassment, intimidation of a dependent, interference with personal liberty, or willful deprivation but does not include reasonable direction of a minor child by a parent or person in loco parentis.  Those persons entitled to the protection of the Act include (i) any person abused by a family or household member; (ii) any high-risk adult with disabilities who is abused, neglected, or exploited by a family or household member; (iii) any minor child or dependent adult in the care of such person; and (iv) any person residing or employed at a private home or public shelter which is housing an abused family or household member. A "high-risk adult with disabilities" means a person aged 18 or over whose physical or mental disability impairs his or her ability to seek or obtain protection from abuse, neglect, or exploitation (750 ILCS 60/103 and 201).

  The information that must be offered by all health care professionals to suspected victims of abuse includes the availability of shelter care through social service agencies or other entities which are located within the same locality in which the professional provides services.  In Springfield, emergency or shelter care services are available to many suspected victims of abuse through the Sojourn Women's Center.  That Center maintains a HOTLINE telephone number -- 544-2484 -- and its regular office telephone is 544-0203.  These shelter care centers also generally provide counseling, advocacy and related support services for abuse victims.

  In addition to the services available through public and private shelter care centers, a suspected victim of abuse should be advised that court orders of protection may be sought, and that assistance in the filing of a petition for such an order is available.  Any person not represented by counsel must be provided, through the circuit clerk's office, simplified forms and clerical assistance to help with the writing and filing of an action for orders of protection (750 ILCS 60/202(d0).  A court must enter an order of protection upon finding that a petitioner has been abused as defined by the Act. Violation of an order of protection can be criminally prosecuted in some instances and through contempt of court proceedings (750 ILCS 60/214 and 223).

  As a provider of health care services required to offer such information to suspected victims of abuse, you are provided good faith immunity from civil liability for any act or omission of the agency providing those services to victims of abuse or for the inadequacy of those services provided by the agency (P.A. 87-436, 1).

  Booklets that explain domestic violence and provide detailed information about resources available for domestic violence victims have been distributed at key locations around the School for your convenience: the Medical Resource Center (Carbondale), Student Affairs Office (Carbondale and Springfield), Medical Library (Springfield), Student Lounge (Springfield), Office of the Associate Dean for Educational Affairs (Springfield), and all Clerkship Coordinator offices (Springfield).

• ILLINOIS ABUSED AND NEGLECTED CHILD REPORTING ACT: NOTIFICATION OF MANDATED REPORTER STATUS

  As a medical student at Southern Illinois University School of Medicine, you are a mandated reporter under the Abused and Neglected Child Reporting Act (Ill. Rev. Stat 1985, ch. 23, pars. 2051 et seq.). This means that you are required to report or cause a report to be made to the child abuse Hotline number (1-800-25A-BUSE) whenever you have reasonable cause to believe that a child known to you in your professional or official capacity may be abused or neglected. There is no charge when calling the Hotline number.  The Hotline operates 24 hours per day, 7 days per week, 365 days per year.

  The privileged quality of communication between you and your patient or client is not grounds for failure to report suspected child abuse or neglect.  If you willfully fail to report suspected child abuse or neglect you may be found guilty of a Class A misdemeanor.

  A brochure with detailed information about child has been distributed at key locations around the School for your convenience: the Medical Resource Center (Carbondale), Student Affairs Office (Carbondale and Springfield), Medical Library (Springfield), Student Lounge (Springfield), Office of the Associate Dean for Educational Affairs (Springfield), and all Clerkship Coordinator offices (Springfield).

• DEALING WITH UNETHICAL OR QUESTIONABLE BEHAVIOR

  If you observe another student engaging in questionable activities (test taking, truthfulness, abuse of drugs, possession of confidential exams, etc.), there are several options available to you. These are listed below in order of increasing severity.  It is up to you to determine which action is appropriate in a given circumstance. Every effort should be made to clear up a situation before filing a formal complaint, an action which should only be used as a last resort to remedy an ongoing questionable situation which cannot otherwise be resolved, or in cases of obvious serious misconduct.

  Regardless of which action you take, if any, it is most important to keep the matter to yourself.  It is absolutely inappropriate to discuss such a situation with anyone other than the parties involved.  The importance of this rule cannot be overemphasized.

  • Approach the student in person and discuss the suspicious activity.  Pointing out to a student that his or her behavior appears questionable will frequently be sufficient to correct the situation.
  • If it is related to testing, notify the proctor of any questionable activity observed during an exam. One of the functions of a proctor is to remedy minor situations so that they do not become major.
  • If the proctor does not correct the situation, inform the instructor whose material is being tested.  This may have to be done after the exam but can help in preventing the situation in the future.
  • If the instructor fails to remedy the situation, notify the block coordinator, your adviser, or some other appropriate administrative person within the school. They can counsel you regarding available options.
  • Finally, a written formal complaint can be filed against the student as outlined in the Student Progress System book.  Be sure to familiarize yourself with the complete procedure involved in processing a formal complaint prior to filing one.

  Since all possible solutions to problems of misconduct should therefore be attempted before filing such a complaint, we hope that these recommendations will assist you in preventing questionable situations from arising or, if they do arise, in dealing with them appropriately.