VCOM College Catalog and Student Handbook

information to others. In general, students are permitted to discuss patient information with medical personnel who are directly involved in providing the patient's care. In some cases, in making a medical presentation, a patient’s condition may be discussed but must be presented without any personally identifiable information. Students must obtain permission for presentations and should not divulge a patient's name or other identifying information that is considered confidential information. Students should not divulge a patient's confidential information whether in formal or in casual comment in any other arena in which they do not have the patient or physician’s permission to do so. Any discussion of a patient, peer, physician or healthcare facility should be a professional discussion and not cause misunderstanding or distrust of the medical care offered at the site. Failure to adhere to this professional behavior constitutes a violation of the VCOM Honor Code. Medical Records/Charting The responsibility given to students for medical records varies among the hospitals and clinics. Some sites allow students to write full progress notes and orders directly into the patient's chart. When this is allowed, notes must be immediately co-signed by the supervising physician and that physician must follow this with her or her physician note. At no time do the student notes serve as the physician preceptor’s notes. Billing must be directly related to the physician preceptor’s notes. Some other hospitals/clinics have separate pages in charts set aside for "Student Progress Notes.” These should also be reviewed and co-signed by the attending physician. Notes are usually written or entered in the SOAP format. If dictation or computerized entry is allowed by students at a particular hospital or clinic, the resulting notes must also be reviewed and approved by the attending. The student is responsible for obtaining charting instructions from the preceptor or rotation coordinator. Medical Records that are falsified or that are left uncompleted when it is the responsibility of the student to complete, are considered a professional or ethical violation and the student will be subject to the policies and procedures in the student handbook that apply to the violation. NOTE: The student is responsible for knowing proper procedure and must sign and date all entries on the medical record by name and educational status (e.g., John Doe, MS 3 or OMS 3). Fatigue Mitigation Providing medical care to patients is physically and mentally demanding. Night shifts, even for those who have had enough rest, cause fatigue. VCOM has adopted fatigue mitigation processes and ensures that there are no negative consequences and/or stigma for using fatigue mitigation strategies. It is important for physicians and students to have adequate rest before and after clinical responsibilities. Signs of fatigue include: • Involuntarily nodding off

• Decreased startle response • Anxiety • Social withdrawal • Degraded motor skills • Tenseness and tremors • Slower reaction time • Labile mood • Poor coordination

• Waves of sleepiness • Problems focusing • Frequent unexplained headaches • Muscular aches and pains • Blurred/double vision • Loss of appetite • Irritability/intolerance • Reduced short-term memory • Lack of interest and drive • Confusion and fearfulness

• Difficulty with short-term recall • Tardiness or absences from work

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