Clinical Supervision Policy

Clinical Supervision Policy

Policy Statement

This policy addresses the expectations around the clinical supervision of medical students. It ensures that medical students in clinical learning situations involving patient care are appropriately supervised at all times to ensure patient and student safety, that the level of responsibility delegated to each student is appropriate to their level of training, and that supervised activities are within the scope of practice of the supervising health professional.

Definitions

All medical students must have direct supervision or indirect supervision with direct supervision immediately available at all times. Medical students may not provide unsupervised patient care.

Direct supervision is where a supervising physician or designated Advanced Practice Provider (NP, PA, CNM) is physically present with the patient and the medical student as care is being provided, and is able to take over care if needed.

Indirect supervision with direct supervision immediately available is where the supervisor is immediately available in the clinical location and can be present with the patient and student.

Supervising clinicians are either faculty members, designated Advanced Practice Provider (NP, PA, CNM) or residents who have been designated to supervise the medical students. Supervising clinicians must hold a faculty appointment at the School of Medicine or, if they do not, must be supervised in their teaching role by a faculty member with an appointment. All supervisors must be appropriately licensed, credentialed, and privileged at the clinical site and may supervise only activities within their own scope of practice.

Intimate Exam refers to pelvic, genitourinary, and rectal exams

Procedure refers to an invasive diagnostic or therapeutic intervention performed at the bedside, in a procedure suite, or in an operating room, such as venipuncture, IV placement, urinary catheter or nasogastric tube placement, suturing, lumbar puncture, paracentesis, or central line placement.

Progressive responsibility refers to the gradual increase in the responsibility delegated to a student as the student demonstrates competence in a specific activity.

Responsible Parties

Supervising Primary Clinical Faculty and Residents are responsible for providing direct or indirect supervision to students as outlined in this policy.

Course, clerkship, and site directors are responsible for adherence to this policy. They orient students and supervisors to this policy and to the clerkship’s list of permitted activities and minimum supervision levels, assign students to appropriate supervisors, and address supervision concerns.

Medical students are responsible for working within the level of supervision assigned, seeking additional supervision when they lack the knowledge or experience to perform an activity safely, and telling the supervisor or clerkship director when they are asked to perform beyond their level of competence.

The Associate Dean of Medical Education and Assistant Dean of Medical Education for Affiliated Sites (ADME-AS) are responsible for oversight on this policy.

The Medical Education Committee approves the minimum supervision standards in this policy and each clerkship’s list of permitted activities and procedures.

Procedures

Initially, the primary clinical supervisor members should designate time to observe the student performing the following: history taking, focused physical exam, clinical problem solving, interaction with patients and patient education.  Once the supervisor has assessed the student’s competence for an activity, as described under “Assessing Competence” below, the student should be provided with the level of responsibility appropriate to their skills and the supervisor should provide increasing levels of responsibility in patient care over time, as appropriate.

Although students may initiate a particular patient encounter on their own with indirect supervision, the supervisor must review the encounter with the student at some point during the patient visit. The faculty is ultimately responsible for the evaluation, treatment, management, and documentation of patient care.  Faculty must complete a note that documents that they were the person responsible for seeing and examining the patient.

Under no circumstances should the following occur:

• A student performs a procedure without direct supervision by a clinician for whom the procedure is within their scope of practice.
• A student gives verbal or telephone orders, or enters orders related to end-of-life care (such as do-not-resuscitate orders).
• A student serves as a chaperone.
• Patient leaves the office/hospital with never having had a direct face-to-face encounter with clinical faculty.
• Primary faculty gives “prior approval” for student to perform intervention (order labs, prescribe meds) without satisfactory review.
• Patient leaves the office/hospital without being informed that assessment/ management plan has been directly reviewed and approved or modified by the faculty.
• Learning in which a student is expected to perform an intervention or participate in an encounter without the prerequisite training and/or adequate supervision.
• Student note provides the only record of the visit.

Documentation Supervision

EMR Documentation

Students are encouraged to write complete notes in the electronic health record (EHR). Each clinical site’s documentation policy determines which types of notes students may write and how student notes are labeled; the clerkship director informs students of these rules at orientation. Supervisors must review all student documentation that is used for billing. In all settings:

• Students use the EHR only after completing the site’s required EHR training, and only through the student access the site assigns.
• Student notes are clearly identified as written by a medical student.
• Students document only care they personally performed or observed, and do not copy another clinician’s documentation as their own.
• The supervisor reviews each student note, verifies the history, physical exam, assessment, and plan, and documents that review.
• Students may pend orders but may not sign them. The supervisor reviews and signs all orders before they are carried out.
• A student note may not serve as the only record of a visit (see “Under no circumstances” above).

CMS Guidelines from February 2, 2018, state: “The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”

Determining the Level of Supervision

The supervising clinician determines the level of supervision for each patient care activity using the following factors:

• The student’s level of training and phase of the curriculum
• The student’s prior experience and demonstrated competence with the specific activity, as directly observed by the supervisor
• The supervisor’s familiarity with the student’s skills
• The acuity and complexity of the patient’s condition and the risk of the activity to the patient
• The clinical site’s policies and the supervisor’s scope of practice

Assessing Competence

Supervisors assess a student’s competence for each activity, not for the student overall, using:

• Direct observation. The supervisor, or a resident designated by the supervisor, watches the student perform the activity, such as a history, physical exam, oral presentation, or procedure, before the student performs it under indirect supervision. For history taking and physical exams, this observation takes place during the student’s first sessions with the supervisor.
• The student’s prior experience. The supervisor asks what the student has done before, including in earlier clerkships, simulation, and skills training, and may review the student’s record of required clinical experiences or procedure log.
• Review of the student’s work. The supervisor checks the accuracy and completeness of the student’s presentations, notes, assessments, and plans, and verifies key findings with the patient.
• Input from others. The supervisor considers information from residents, other supervisors, and the clerkship director, including mid-clerkship feedback.

Assessment of readiness starts with a student’s self-assessment of readiness. Supervisors should ask students how ready they feel before assigning an activity.  This alone does not establish competence. Until a supervisor has personally observed or verified a student’s competence in an activity, the student performs that activity under direct supervision. The exceptions are history taking and review of records, which the table below allows under indirect supervision from the start.

When in doubt, the supervisor should provide a higher level of supervision. As a student demonstrates competence in a specific activity, the supervisor may move from direct to indirect supervision for that activity. Competence demonstrated with one activity, patient, or supervisor does not automatically transfer to another.

Each clerkship director maintains a list of the required encounters and procedures students may perform in that clerkship and the minimum level of supervision for each, consistent with the table below. Clerkships may require a higher level of supervision but not a lower one. The lists are approved by the Medical Education Committee and shared with students and supervisors at orientation.

Minimum supervision for common activities

When a student believes they are being asked to perform beyond their level of competence, the student must promptly tell the supervisor and may decline the activity without penalty. The supervisor must address the concern and restructure the activity to provide appropriate supervision.

Intimate Exams

Students participating in an intimate exam with a patient must have a chaperone with them, irrespective of the gender of the patient or the student. The chaperone must be an MD/DO (residents included), NP, PA, or CNM.  Permission to participate in an intimate exam must be obtained by the supervisor in advance of the examination itself.  The patient has the right to decline student attendance at any examination. If a student is unable to perform any intimate exam due to patient preference, the student’s evaluation will not be impacted and if necessary, the clerkship director will provide an alternative experience.

Home Visits

Certain rotations have home visits. The clerkship director needs to provide complete instructions regarding the home visit and expectations for the student.

Home visit safety

Student and patient safety is a priority for home visits.  Students are required to go to their home visit with another student or clinician (MD, DO, NP, PA, RN, CNM, Resident, etc.). At no time should a student participate in an experience where they are in danger or feel uncomfortable.  The site director or primary faculty should assist the student in identifying an appropriate patient for their home visit with respect to educational, patient care, logistical, and safety goals.  Students are encouraged to talk with their primary faculty or the clerkship director if they have questions or concerns at any point.  The student should notify the primary faculty or a designated staff member of the date and location of their home visit before they go to the patient’s home.

Monitoring

Course and Clerkship Directors monitor this policy through direct feedback from students, discussions with site directors and faculty, and as part of the annual educational quality improvement process.

The Affiliated Sites Office reviews clinical supervision during scheduled site visits. The Medical Education Office monitors student feedback regarding clinical supervision on the annual end of third year survey.

Students may report concerns about clinical supervision at any time, confidentially and without fear of retaliation, to the clerkship director, through the Appropriate Treatment in Medicine (ATM) reporting link, or on end-of-clerkship evaluations. Clerkship directors review supervision items on end-of-clerkship evaluations and report concerns and actions to the Medical Education Committee at least annually. The affiliated sites and Medical Education Office confirm that supervising clinicians hold appropriate appointments.

Non-compliance is reported to the Associate Dean of Medical Education for action.

Approved by the Medical Education Committee on October 23, 2026.