ROWAN UNIVERSITY POLICY

Title: Patient Care Supervision
Subject: Academic Affairs
Policy No: AA:2021:03
Applies: RowanSOM
Issuing Authority: Dr. Thomas Cavalieri, Dean, RowanSOM
Responsible Officer: Dr. Thomas Cavalieri, Dean, RowanSOM
Adopted: 06/06/2021
Last Revision: 08/24/2021
Last Reviewed: 08/24/2021

I.     PURPOSE

This policy is intended to inform students that as a medical student, they are a vital member of the healthcare team but are NOT, however, a licensed-health care provider and until they have graduated, completed residency and are licensed, they cannot engage in the unsupervised practice of medicine. It is a violation of both New Jersey law and a violation of RowanSOM policy for any unlicensed person to engage in or attempt to engage in the unlicensed practice of medicine.

II.    ACCOUNTABILITY

Under the direction of the Dean, the Associate Dean for Curriculum, and the Assistant Dean for Clinical Education shall ensure compliance with and implement this policy

III.   APPLICABILITY

This policy applies to all RowanSOM Students.

IV.   DEFINITIONS

1. Direct Supervision of a Medical Student: Direct supervision of a medical student by a licensed provider who is available in the facility at the time the student is providing care to any patient. The licensed provider must be present in their office suite or on hospital grounds and immediately available to furnish assistance and direction throughout the performance of the function/procedure. It does not mean that the physician must be present in the room when the function/procedure is performed.
2. Supervision Requiring the Personal Presence of a Licensed Healthcare Provider: The licensed provider must be in attendance in the room from beginning to end, without interruption, during the performance of the function/procedure.
3. Limited Physical Exam: This includes such components as the head/neck, skin, chest, cardiac, abdominal, neurologic and musculoskeletal exams; this specifically excludes genitourinary, breast and rectal exams.
   1. Rational: RowanSOM is committed to providing quality clinical clerkship learning experiences for our students in an environment, which fosters delivery of exceptional quality care while emphasizing both student and patient safety. Therefore, students engaged in patient care at any RowanSOM medical practice or as participants in patient care related activities at any clinical clerkship training site shall do so under the supervision of a licensed health care provider who has been credentialed to provide that scope of care. Visiting students training at RowanSOM facilities or with RowanSOM employed faculty shall be similarly supervised. Specific guidance is provided in further detail below.
   2. Unsigned Notes: Unsigned notes are not progress notes. If a note is co-signed, then it becomes a part of the note in the chart. Student notes should not be relied upon and are for educational use only. The physician is responsible for the note

V.  POLICY

The regulated practice of medicine includes such unsupervised activities as independently making and providing a diagnosis to a patient, the rendering of medical care or advice, prescribing medications, performing procedures, and all other activities normally performed by physicians or other licensed professionals. Students on clinical clerkships may participate in patient care activities, but must recognize that as students they are limited in their scope of training to perform the practice activities above ONLY in supervised settings such as hospitals, teaching clinics, and training sites under the supervision of a licensed health care provider. At no time should a student assume independent responsibility for the care of any patient, provide a diagnosis to a patient, prescribe medication, order tests, or render care without supervision and authorization of a supervising licensed healthcare provider. Further, no student is authorized to receive or to collect for himself/herself or for any other person, any fee or gratuity for professional service they provide during the course of their clerkship training. Any student delivering unsupervised medical care is engaging in the unlicensed practice of medicine, which violates New Jersey Law and RowanSOM policy. Medical students who engage in such activities, may lose protection under RowanSOM’s Professional liability Insurance, and may face disciplinary action at RowanSOM including dismissal. Most importantly, such conduct as engaging in the unlicensed practice of medicine can result in civil and /or criminal actions being filed against the student.

NOTE: While some medical students may be fully licensed in other health care disciplines/professions (for example, Physical Therapists, RN’s, PA’s, Chiropractors, Podiatrists, Dentists, etc.), they may NOT exercise the rights and responsibilities of their license while simultaneously performing their duties and responsibilities as a medical student on clinical clerkship rotations.

1. RowanSOM 3^rd and 4^th year students engaged in patient care activities are guests at a clerkship site and are there to develop and expand their fund of knowledge in the practice of medicine. The student shall at a minimum at all times, be under the direct supervision of a duly licensed healthcare provider who retains privileges for the scope of care being provided unless performing any of the procedures detailed below which requires that supervision is through the personal presence of a licensed healthcare provider. A licensed healthcare provider or a similarly credentialed designee (resident or fellow with approved privileges) must be immediately available in the facility where the learning activity is taking place. Students who have demonstrated competence to the licensed healthcare provider, may perform patient histories and limited physical examinations without personal licensed healthcare provider supervision if directed to do so by the licensed healthcare provider. After collecting data from the history and limited physical examination, students are encouraged to develop a differential diagnosis and plan of care, which they are only authorized to discuss and share with members of the clinical clerkship team. Students are not to discuss their findings with the patient or attempt to provide a diagnosis to the patient without the expressed authority of the supervising licensed healthcare provider.
2. RowanSOM students may perform such additional tasks as may be directed by a supervising health care provider upon demonstrating competence to perform those tasks in accordance with the scope of duties detailed in the outline below. In most instances, the provision of patient care shall require the immediate presence of a duly credentialed licensed supervising healthcare provider who has ascertained the students’ level of knowledge, skill, and proficiency.
3. Students who fail to follow procedures for clinical supervision may be removed from patient care activities at the discretion of the course/clerkship director, Academic Administration of RowanSOM, and referred to the RowanSOM Hearing Board for disciplinary review.
4. Faculty who fail to observe the supervision policy may be removed from participation in training medical students and may be further subject to disciplinary action as determined by the Dean.

VI. ATTACHMENTS

1. Attachment 1: Malpractice Insurance
2. Attachment 2: Guidelines for Supervision during Clinical ClerkshipsAttachment 3: Scope of Duties Permitted
3. Attachment 3: Scope of Duties Permitted
4. Attachment 4: Scope of Duties Prohibited

ATTACHMENT 1
MALPRACTICE INSURANCE

The University provides Liability Insurance for its faculty and students, which is provided through a program of Self-Insurance governed under the terms and provisions of the New Jersey Tort Claims Act (N.J.S.A. 59:1-1 et seq.), and the New Jersey Contractual Liability Act (N.J.S.A. 59:13-1 et seq.).

ATTACHMENT 2
GUIDELINES FOR SUPERVISION DURING CLINICAL CLERKSHIPS

1. Medical students on clinical clerkships shall at all times and at a minimum be under the direct supervision of a licensed health care provider or his/her licensed health care designee for this purpose.
2. Medical students on clinical clerkships shall assume responsibility for and perform their assigned duties in conformance with the rules and regulations of the clinical clerkship training site.
3. When requested or required by the supervising licensed health care provider, medical students on clinical clerkships are permitted to take a history and perform limited physical examinations of the patient. Histories and limited physical examinations will be documented and may be signed by the medical student according to the rules and regulations of the clinical clerkship training site. The histories and limited physical examinations performed by medical students should be reviewed by the supervising licensed health care provider as an educational modality, and be reviewed with the medical student.
4. Progress notes may be written by medical students under the direction of a supervising licensed health care provider. Progress notes must be countersigned within the time required by the rules and regulations of the clinical clerkship training site.
5. Medical students on clinical clerkships shall not order any examinations, tests, medications, or procedures without consulting and obtaining the authorization of the supervising licensed health care provider. Medical students on clinical clerkships shall only write prescriptions as an educational activity.
6. Medical students on clinical clerkships shall be required and encouraged to participate in the utilization of osteopathic manipulative treatment (OMT) when ordered. OMT may be performed under the direct supervision of a licensed supervising healthcare provider however students are PROHIBITED from independently performing any treatment techniques requiring HVLA which requires Personal Licensed Healthcare Provider Supervision by a provider who possesses the scope of training to perform and supervise HVLA.
7. Medical students on clinical clerkships shall learn and perform procedures under appropriate and proper supervision in those areas where the training site regulations permit such instruction. In addition to the general regulations, medical students shall abide by all specific departmental regulations of the training site.
8. RowanSOM is committed to ensuring that licensed healthcare professionals providing any healthcare services or have established a therapeutic relationship with a medical student assigned to them will recuse from the academic assessment or promotion of the student. If a medical student is assigned to a supervising licensed healthcare provider with whom they have a therapeutic relationship, they must contact the Clerkship Director or the Department of Clinical Education, so they can be reassigned.
9. The information contained in this policy will be provided to students through publication in our student handbook and clinical education website and manual. In addition, a link to this policy will be incorporated into clinical clerkship syllabi available on Canvas. It is also incorporated into course and clerkship Blackboard/canvas sites, course and clerkship orientation discussions. This information is also provided in the Introductory Clinical Skills Orientation Course prior to students beginning clinical clerkships, and will be reinforced during the 4th year Fundamentals of Medicine Course.

ATTACHMENT 3
SCOPE OF DUTIES PERMITTED

While on clerkship rotations, Medical Students will be supervised by a licensed health care provider who is credentialed to provide that level and scope of care of that particular clerkship specialty. Each student’s essential learning task while on clerkship rotations is to improve the ability to do the following:

1. Perform an accurate medical history and physical exam based on the patients presenting complaint and appropriate to the clinical setting.
2. Formulate a differential diagnosis appropriate to the patient and the clinical setting.
3. Order and accurately interpret tests and procedures in order to narrow the differential diagnosis to a working diagnosis.
4. Accurately describe and/or perform procedures to diagnose and treat the patient’s problem.
5. Develop a treatment plan appropriate to the patient’s problems and student’s findings.
6. Work ethically and professionally with patients and members of the healthcare team.

By student year, the scope of duties medical students may perform in order to complete the above learning tasks are:

1. First Year Students: First Year Students are permitted to perform the following functions only:
   1. Observation and follow only
   2. History taking under the Personal Presence of a Licensed Healthcare Provider Supervision, until the licensed healthcare provider determines competency, after which the student may perform history taking direct physician supervision.
2. Second Year Students: Second year students are permitted to perform the following functions only:
   1. All of the functions permitted for First Year Students, as stated above
   2. History taking under direct physician supervision
   3. Limited Physical Examination under Supervision Requiring the Personal Presence of a Licensed Healthcare Provider until the licensed healthcare provider determines competency, after which student may perform Limited Physical Examination under direct
3. Third and Fourth Year Students: Third and Fourth Year students are permitted to perform the following functions only:
   1. All functions permitted for First and Second Year Students, as stated above
   2. Under direct licensed healthcare provider supervision, may ‘round’ on patients, to include:
      1. Gathering lab, radiology, nursing and other information/results
      2. Obtaining history
      3. Performing Limited Physical Exam
      4. Developing interim assessments and recommendations
   3. For genitourinary, breast or rectal exam, student may perform exam under Supervision Requiring the Personal Presence of a Licensed Healthcare Provider, if the supervising licensed healthcare provider determines the student’s readiness and a gender appropriate chaperone is present, as indicated.
   4. Under direct supervision of a licensed healthcare provider, a student may write student notes regarding E/M services or procedures:
      1. If such student notes are to be placed in the patient chart, they must be clearly labeled as student notes and co-signed by the supervising healthcare provider in accordance with the established rules/regulations of the training site.
      2. Non-signed/unsigned student notes are just that – student notes. They are not the progress note for the patient and should never be allowed to be used as such.
      3. If student notes are strictly for the educational experience of the student, and will not be placed in the chart, they must not contain any patient identifiers and should be shredded or destroyed as consistent with HIPAA policies.
   5. If permissible at the clerkship site, students may write orders on the chart under Supervision Requiring the Personal Presence of a Licensed Healthcare Provider, and must be immediately reviewed and countersigned by the supervising licensed healthcare provider before any action is taken based on those orders.
   6. The following procedures may be performed by 3rd or 4th year medical students only if:
      1. The supervising licensed healthcare provider determines the student’s readiness to start to perform the procedure under Supervision Requiring the Personal Presence of a Licensed Healthcare Provider,
      2. The supervising healthcare provider has the appropriate privileges, competency, and teaching proficiency to perform and educate medical students in their performance
      3. Appropriate patient consent has been obtained.
   7. The following procedures must be performed under the Supervision Requiring the Personal Presence of a Licensed Healthcare Provider, until the licensed healthcare provider determines the student is competent to perform the procedure under direct supervision:
      1. Perform insertion of IVs or draw blood – stick attempts limited to three (3) per patient
      2. Administration of PPD’s or immunizations
   8. The following procedures must always be under Supervision Requiring the Personal Presence of a Licensed Healthcare Provider when performed by a medical student:
      1. Airway Management (i.e. nasotracheal, oropharyngeal, etc.)
      2. APGAR and Dubowitz/Ballard Assessment
      3. Arterial puncture – for blood gases (ABG)
      4. Arthrocentesis
      5. Breast Exam
      6. Cardiac ultrasound and Doppler studies
      7. Casting/Splinting, of any body region
      8. PAP and Pelvic examinations
      9. Colposcopy
      10. Ear, Evaluation and Treatment – Cerumen Removal
      11. EKG Interpretation
      12. Episiotomy and repair
      13. Eye, Evaluation and Treatment –for Corneal Abrasion, foreign body
      14. Intravascular Access, Central
      15. Lumbar Puncture
      16. Nasogastric Tube Placement
      17. Newborn Management, Uncomplicated Delivery
      18. Newborn Management – Newborn Resuscitation
      19. Nose, Evaluation and Treatment – foreign body removal, Epistaxis Control
      20. HVLA Osteopathic Manipulation Treatment (OMT)
      21. Provide Health Promotion / Disease Prevention Counseling
      22. Psychiatric Assessment
      23. Pulmonary Function Tests
      24. Remove sutures or staples
      25. Resuscitation Team Member (specify role i.e. Leader, Compressor, etc.)
      26. Skin Lesion Excision
      27. Surgical Assistant
      28. Suturing, extremities, trunk, face (indicate type of anesthesia)
      29. Ultrasound, bedside – FAST (Focused Assessment with Sonography for Trauma)
      30. Ultrasound, Other than FAST
      31. Urinalysis by Dipstick
      32. Urinary Catheter Insertion
      33. Vaginal Delivery, Spontaneous
      34. X-Ray Studies (i.e. chest, abdominal series, extremities etc.)

The above notwithstanding, duties and activities of medical students must not conflict with hospital policies.

 ATTACHMENT 4
SCOPE OF DUTIES PROHIBITED

Medical Students are strictly prohibited from performing any and all functions that are not specifically permitted. Additionally, medical students are specifically prohibited from performing the following:

1. Give verbal or telephone orders.
2. Write orders regarding end-of-life, such as DNR
3. Write prescriptions unless for educational experiences only