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Medical Student Documentation Policy

Description: 

Please see the respective policy below.

MEDICAL STUDENT DOCUMENTATION

It is the policy of SIU, (collectively, SIU SOM and SIU HC), to consistently and fully comply with all laws and regulations pertaining to the training of medical students.

I. Background

The purpose of this policy is to set forth the process that will be used by SIU to supervise, document, and bill for clinical services when a medical student is involved in the documentation of the care of patients to ensure compliance with all applicable laws and regulations. For purposes of this section, the following definitions apply.

Teaching Physician - A physician (other than a resident) who involves residents in the care of his or her patients.

Resident - An individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the Fiscal Intermediary (FI). Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of "resident".

Student - An individual who participates in an accredited educational program (e.g., a medical school) that is not an approved GME program. A medical student is an individual enrolled in an academic program leading to a doctor of medicine degree (MD) or a doctor of osteopathy (DO).  A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student.   Other medically related learners in formal and structured educational programs leading up to graduation as physician assistants, nurse practitioners, etc. are NOT included under this policy.

Physically Present - The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

II. Policy

The following are the requirements related to supervision of students and the use of medical record documentation entered by students of patient care services.

A. Evaluation and Management (E/M) Service Documentation Provided By Students

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth for teaching physician billing.

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.

Teaching Physician Requirements

1. Teaching physician must personally perform (or re-perform) the “key” components of the service:

  • History of Present Illness
  • Physical Exam
  • Medical Decision making

2. If the Teaching physician relies on the student’s documentation,  the Teaching physician must verify in the medical record all student documentation or findings and must add the teaching physician attestation as noted below:

A student assisted with the documentation of this service.I saw and personally examined the patient and reviewed and verified all information documented by the student and made modifications to such information, when appropriate.

3. If both a medical student and a resident documents in the note, the Teaching physician must attest to the student’s documentation and the resident’s participation in the care of the patient:

A student assisted with the documentation of this service.I saw and personally examined the patient and reviewed and verified all information documented by the student and made modifications to such information, when appropriate.

I saw and personally examined the patient and discussed the case with the resident.  I have reviewed the resident’s note and agree with the content and plan as written.

4. The Teaching physician must sign and date their personally prepared documentation.

Medical Student Requirements

Medical Students who document in the medical record, must check the medical student documentation box to insert the following statement:

I participated in the documentation of this service as a medical student.

By inserting the medical student statement, the name of the medical student involved in the care will be inserted and time stamped as required by electronic health records auditing purposes.

B. Procedures

For billing purposes, the Centers for Medicare & Medicaid Services (CMS) does not allow medical students to document procedures.This policy is related to Evaluation and Management (E/M) services only.

 

C. Primary Care Exception Clinics

The Primary Care Exception does not apply to medical student documentation.

Under the Primary Care Exception, the teaching physician is not required to perform or re-perform the billable portions of the E/M visit provided by residents.  This exception does not apply to medical students and any reliance on medical student documentation must follow the process outlined above in Section II under Teaching Physician Requirements.

D. Medical Student as a Scribe

Medical students are NOT eligible to act as a scribe while acting educationally as a student. 

A scribe is defined as an individual who is present during the Teaching clinician’s performance of a clinical service and documents on behalf of the clinician everything performed and said during the course of the service, without being clinically involved in the medical care of the patient. (e.g., a human tape recorder)

EXCEPTION: A medical student may act as a scribe if their sole purpose is to record the service being rendered by the clinician and they are doing so while employed by or under contract with SIU SOM or SIU HC.For example, a first year medical student during summer break might act as a scribe during a summer employment.

Adopted: 

September 10, 2008, revised 2/21/17, 4/24/18

Contact:  Compliance Officer

Revisions:

Approved by OCP: 4/11/2018

Approved by Quality and Safety:  4/24/18     

Revised: 4/24/2018

Approved by Executive Committee:  9/10/18

References:

SIU SOM Student Handbook - Scribes Policy.

CMS Medicare Claims Processing Manual, Change request 10412