Pre-Accreditation Element 5.4.1 - Patient Care Supervision Policies and Procedures - Clinical supervision guidance

Sep 29, 2026

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Pre-Accreditation Element 5.4.1 establishes Xavier University College of Osteopathic Medicine policies for supervising medical students during clinical learning situations involving patient care. It requires direct oversight by a fully licensed health care professional at all times and clarifies that supervised activities must remain within the supervisor’s scope of practice. The document defines supervision types (direct and indirect), outlines student authority and limits, specifies responsibilities for consent, HIPAA compliance, and prohibited actions, and lists clinical activities permitted or required under each supervision level. It also provides review scheduling and responsible parties.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Purpose

Policy

Accreditation requirement and supervision scope

Definitions / Abbreviations

Procedure / Protocol

Supervision responsibility and licensing/credentialing

Student authority and responsibility

Student supervision types (Direct vs Indirect)

Activities under indirect supervision

Activities requiring direct supervision

Telemedicine requirements

Exhibits

Related Policy/Policies

Review schedule

Pre-Accreditation Element 5.4.1: Patient Care Supervision Policies and Procedures XAVIER UNIVERSITY College of Osteopathic Medicine Medical Student Supervision in Clinical Learning Situations Policy Effective: September 1, 2025 Last Revision: (Date) Next Review: June 30, 2026 Responsible College Officer: Assistant/Associate Dean, Clinical Education & GME Scope: XUCOM Medical Students involved in Patient Care Distribution List: XUCOM Administration, Faculty, Staff, and Students; Preceptors; Webpage A. PURPOSE To guide the activities of medical students and their supervisors in clinical learning situations to ensure the safety of both patients and students. B. POLICY Element 5.4 of the Commission on Osteopathic College Accreditation (COCA) New and Developing Accreditation Standards (effective September 26, 2023; edited October 1, 2024) requires that a COM ensure that osteopathic students in clinical learning situations involving patient care are under direct supervision by a licensed health care professional at all times in order to ensure patient safety. The COM must ensure that all supervised activities are within the scope of practice of the supervising health care professional. Students must have clear guidelines on their role in care and the limits of their scope of authority. C. DEFINITIONS / ABBREVIATIONS COCA / Commission on Osteopathic College Accreditation OMM / Osteopathic Manual Medicine XUCOM / Xavier University College of Osteopathic Medicine D. PROCEDURE / PROTOCOL XUCOM students in clinical learning situations that involve patient care must be supervised by a physician (DO or MD), advance practice provider (nurse practitioner, physician assistant/associate) or other fully licensed practitioner practicing within the scope of his/her license, expertise, and credentialing body of the clinical site (as applicable) . The supervising health care provider (physician or other health care professional) is responsible for the activities of each student seeing patients on his/her rotation. The supervisor must have an active license, be credentialed by XUCOM, and practicing within the scope of practice defined/described by their license and expertise. The quality of student supervision is the responsibility of the XUCOM Associate Regional Dean with guidance and support from the Assistant/Associate Dean of Clinical Education and GME, and the Clinical Division Chairs. Pre-Accreditation Element 5.4.1: Patient Care Supervision Policies and Procedures XUCOM students that have questions or concerns related to or regarding clinical supervision or safety issues in any clinical learning situation should contact the Assistant/Associate Dean of Clinical Education & GME. Student Authority and Responsibility 1. Students must inform each patient of their level of training and obtain consent to participate in the delivery of their care. a. If an XUCOM student has a doctorate degree in anther discipline, he/she may not introduce themselves to a patient as “Dr.” while on a clinical rotation. 2. Students must abide by all HIPAA regulations. 3. Students must abide by all institutional policies related to the delivery of patient care. 4. Students may not independently write prescriptions. 5. Student may not authorize orders. 6. Students may not independently document patient encounters. 7. Students may not bill for any of their activities. 8. Supervisors may delegate responsibility after considering: a. The level of the student’s training and competence. b. The experience of the student with the clinical situation. c. The acuity of the clinical situation. d. The risk to the patient and student. 9. Students may not participate in the care of other medical students. Student Supervision (see Appendix) Medical students should be supervised during all aspects of patient care. There are two (2) types of student supervision: 1. Direct Supervision a. The supervisor

FAQs

What is the purpose of Element 5.4.1?

It guides medical students and their supervisors during clinical learning situations to ensure safety for both patients and students.

Who must supervise XUCOM students in patient care settings?

Students must be supervised by a physician (DO or MD), an advance practice provider, or another fully licensed practitioner practicing within the scope of their license and credentials.

What is the difference between direct and indirect supervision?

Direct supervision means the supervisor is physically present with the student and patient. Indirect supervision means the supervisor is at the site of care and immediately available to join the student and provide direct supervision.

Sep 29, 2026

Uploaded by Ivy