Guidelines for Clinical Activities
ROLES AND RESPONSIBILITIES OF MEDICAL STUDENTS
It is essential that SIU students be immediately recognizable as medical students to patients, house staff members, and staff of all affiliated hospitals and outpatient care centers. In accordance with the School of Medicine directive, students are expected to wear the standard short white coat with the SIU logo and identification badge. During clinical work, students will be introduced to patients as medical students. This term should not be augmented by modifying statements such as "student physician" or "student doctor."
All patients seen by medical students are the ultimate responsibility of the faculty physicians to whom those students are assigned. Students in clinical learning situations involving patient care must be appropriately supervised at all times. While students learn through graded responsibility as their skills progress, supervision must always ensure patient and student safety. Students are only to perform patient care activities and procedures after appropriate instruction and demonstration of necessary skill. The level of responsibility delegated to the student by the supervisor will be appropriate for the student's level of training, and the activities supervised will be within the scope of practice of the supervising health professional. Students may decline to perform any patient care element requested by a resident or attending physician for which they believe they have not received necessary instruction, have not acquired the necessary skill, or do not feel appropriately supervised.
MEDICAL RECORDS IN THE HOSPITALS AND CLINICS
Your ability to access medical records in the hospitals and the SIU Clinics is essential to provide appropriate patient care and to facilitate the learning experience. Students are reminded, however, that these records are confidential and should only be accessed as needed for the purpose of providing health care to patients. You are expected to abide by the strictest policies of confidentiality when dealing with medical records in either paper or electronic format. Any violations will be treated as serious matters and may be subject to University, State and federal privacy laws regarding patient health information. You are entitled to review your own medical record, but you cannot legally access the records of family or friends without written authorization from the patient or her/his agent.
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 on paper charts 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. Whether in paper or electronic form, be mindful that the medical record is a professional document and one might be asked to discuss chart entries in court, one should avoid sarcasm, humor, disparaging remarks about the patient or other providers involved, and speculation as to what might have occurred if other treatments or interventions had been provided.
You will be given access to the Electronic Health Records (EHR) at Memorial Medical Center and St. John's Hospital. The SIU clinical departments are in the process of transitioning from paper to electronic format, and training, access, and level of use will be an ongoing project throughout the coming year. Please be patient and if you run into problems with EHR systems in any of these venues, clerkship faculty and staff will be able to assist.
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 to friends or relatives, representatives from the news media or law enforcement divisions without prior consent of the hospital administration. Any requests for information should be referred to the patient's attending physician, or to the patient himself or herself. 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.
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, review 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. Progress notes on the patients' charts should be in standard SOAP format, which conforms to accrediting body requirements. Information concerning operative or other 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 to obtain a countersignature. You should not expect or allow your 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.
- STUDENT DICTATION (WHEN APPLICABLE)
Year Three students may dictate in SIU Clinics only. Year Four students may dictate in SIU Clinics and both hospitals.
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.
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.
Handling of Patient Records
Except as permitted by Illinois law, you cannot release information pertaining to a patient unless specifically authorized to do so by the patient or the patient's legal representative. 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. Failure to control access to confidential patient information (in paper, electronic, or other form) 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 your assigned duties is inappropriate. Therefore, discussion of any particular case must be limited to those parties with whom you must interact to assure the successful fulfillment of your duty to the patient.
Other Professional Conduct
Unless authorized or required to do so, you 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. Students are reminded that a violation of patient confidentiality as described above 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.
- ILLINOIS DOMESTIC VIOLENCE ACT: NOTIFICATION OF DUTY TO DISCLOSE & ILLINOIS ELDER ABUSE & NEGLECT ACT: NOTIFICATION OF DUTY TO REPORT
Domestic Violence: 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 victims of abuse through Sojourn Shelter and Services. That Center maintains a HOTLINE telephone number -- 726-5200 -- and its regular office telephone is 726-5100. This organization also provides 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).
Elder Abuse Reporting: You are mandated to report suspected cases of elder abuse, neglect or financial exploitation discovered while performing your clinical responsibilities, as outlined in the Illinois Elder Abuse and Neglect Act, (320 ILCS 20/1). You must report within 24 hours to the Illinois Department on Aging (1-800-252-8966) or, in Sangamon County, to Senior Services of Central Illinois (217-528-4035) when you suspect mistreatment of any Illinois resident 60 years of age or older who, because of dysfunction, is unable to report the mistreatment themselves. “Abuse” under the act is defined as “causing any physical, mental or sexual injury to an eligible adult, including exploitation of such adult's financial resources.” “Neglect” means “another individual's failure to provide an eligible adult with, or willful withholding from, an eligible adult the necessities of life including, but not limited to, food, clothing, shelter or health care,” This does not, however, mean that neglect can be construed when a licensed health care professional did or did not provide certain health care services.
If you are unsure whether the patient has the ability to make the report themselves, you may make a voluntary report, and voluntary reporting is encouraged in all suspected cases. Further guidance may be found in the Illinois Department on Aging report, “Reporting Elder Abuse: What Professionals Need to Know,” available at http://www.state.il.us/aging/1news_pubs/publications/ea-prof_book.pdf.
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).
- ILLINOIS ABUSED & 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.
- DEALING WITH UNETHICAL OR QUESTIONABLE BEHAVIOR
Please see the SIU School of Medicine Honor Code and the Standards of Conduct