Title: 02.04.006-Clinical Documentation

Policy Number: 02.04.006

Policy Title: Clinical Documentation

Status: Active

Policy:

In order to obtain credit for clinical/field Internships, the student must fully document their Patient Care Reports (PCRs), including completed narratives, within their designated documentation system. Students should familiarize themselves with the specific program requirements for this by reviewing their program or course syllabus. PCRs from internships must be documented within 48 hours of the end of the clinical/field internship shift in order to be accepted.  

In the event a student reports being unable to complete their PCR documentation within the required timeframe, a faculty member may unlock the shift to allow the student to complete the documentation, provided it has been no more than seven (7) calendar days since the shift end date and time. The student will then be granted an additional 24 hours to complete the required documentation. If the documentation is not completed within that extended timeframe, any patients with incomplete or insufficient documentation will be deprecated from the student’s clinical portfolio, which includes the Student Minimum Competency (SMC) Matrix for Advanced and Paramedic students. 

All internships require that documents be signed by a preceptor such as a nurse or physician in the clinical setting or an EMT or Paramedic in the field setting. Any falsified record of documentation by the student is grounds for immediate dismissal from the program with a failing grade. If a student fails to obtain the required end-of-shift signoff, faculty will conduct an initial review, focusing on reporting and timeliness, compliance and performance, preceptor interaction, and previous clinical/field internship history. If the review produces reason to believe the failure to obtain proper preceptor sign off was an anomaly or justifiable due to unusual circumstances, then the faculty will review the clinical shift(s) to determine whether the student may count the shift(s) and/or patients.  

If the affected shift(s) is found to be justifiable and constitutes less than 20% of the student's hours and/or involves less than 10% of the recorded patients, then the student may be eligible to count the shift and associated patient contacts. However, if the student fails to obtain both the mandatory end-of-shift evaluations and the end-of-shift signoff, then the patients treated during that shift will not count toward the student’s clinical portfolio requirements and the student will lose hour credit for any impacted shift. 

If students fail to achieve the minimum skills exposure during their clinical/field internships, the Program Director or the Teaching Team may require them to attend additional hours in an attempt to achieve the minimum requirements. Additional hours may also be required if a student is unsuccessful at certain skills. 

During times when scheduling at a hospital or ER facility is difficult due to extenuating circumstances, the Program Director or the Teaching Team may approve the substitution of ER hours with EMS hours.