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Guidelines and Workflow for Student Billable Notes in Patient Charts

Medical student documentation is the process of medical students documenting clinical services, including history, physical exam and/or medical decision-making, in a patient’s electronic medical record. Historically, the teaching physician was required to re-document the medical student’s entries.

A 2018 ruling by the Centers for Medicare and Medicaid Services (CMS) states that student notes may be billable if there is direct presence of the attending or resident during the History, Physical Evaluation and Management.

Read more about the ruling on the American Medical Association website.

Certain departments across Penn State Milton S. Hershey Medical Center are implementing student billable notes. In order to comply with the hospital’s policy, there are specific requirements and documentation guidelines students, residents and attendings must follow. Each provider should check with their department chair to see if student billable notes are applicable in their area.

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Working With Student Billable Notes: Guidelines

  • To satisfy the physical presence requirement of the CMS policy, the attending and/or intern/resident must be present with the student as they perform the history, physical exam and medical decision-making.
  • If the resident/intern is who is physically present with the student, the note must have both resident/intern and attending attestations (see the workflow section of this page).
  • To satisfy physical presence requirement on rounds, patient-centered bedside rounds are recommended.
  • There is one resident/intern attestation (see resident/intern workflow guide).
  • There are two attending attestations based on the resident’s presence (see attending workflow guide).
  • The number of student billable notes should be limited to two per day per clerkship student. (Students should write non-billable medical student notes when carrying more than two patients.) Clerkship students should send their notes to interns to co-sign.
  • An acting intern (AI) should be writing notes with the resident. There is no specific limit to the number of notes for the AI.
  • Residents and attendings may alter the medical student note with strikethrough/deletion/additions only if using a separate font style, such as bold or italic text, to indicate changes. Color should not be used to indicate changes.

Policy

Recent Changes Expand answer

Student autotext

Students must indicate that the note is a medical student note using the following autotext in orange. This can be removed by the attending when signing the note.

This note was written by a medical student. Preliminary report status should be regarded as NOT reviewed by an attending physician. Finalized report status indicates that the attending has reviewed the note and agrees with the plan.

Note alterations by residents/attendings

Residents and attendings may alter the medical student note with strikethrough/deletion/additions only if using a separate font style, such as bold or italic text, to indicate changes. Color should not be used to indicate changes.

My resident was physically present with the medical student and patient, and I have personally performed/re-performed the physical exam and medical decision-making activities for the service. I verify that the history, physical exam and medical decision-making as documented in the note by the medical student are accurate except…

Workflow

Student Workflow Expand answer

Did the student see the patient with a resident and/or attending during initial history and physical or bedside rounds?

If no: This is not a billable note. Open a “Medical Student H+P Note” or “Medical Student Progress Note.”

If yes: This is a billable note. To proceed:

  • Open an “H&P Note” or “Medicine Inpt Progress Note.”
  • Add this text under the note title in orange:
    This note was written by a medical student. Preliminary report status should be regarded as NOT reviewed by an attending physician. Finalized report status indicates that the attending has reviewed the note and agrees with the plan.

If billable, was a resident (either an intern or a senior resident) present?

If no: Add the attending as a cosigner.

If yes: Add the resident (intern or senior resident) and the attending both as cosigners.

Resident/Intern Workflow Expand answer

Did the resident see the patient with the student during initial history and physical or bedside rounds?

If no:

  • Was an attending physically present with the student?
    • If yes: This is a billable note. The student should write the note with the attending as cosigner and attending attestation. No resident attestation is required.
    • If no: This is not a billable note. The student must write a separate “Medical Student H+P Note” or “Medical Student Progress Note.”

If yes: This is a billable note. To proceed:

  • The student should write an “H&P Note” or a “Medicine Inpt Progress Note.”
  • The resident and attending are cosigners. First, the resident reviews the note and provides feedback.
  • Both resident and attending attestation are required. The resident should use the following attestation:
    As the resident, I was physically present with the medical student while they performed the history, physical exam and medical decision-making. I verify that the medical student’s note is accurate and reflects the services provided except…
Attending Workflow Expand answer

Did a resident see the patient with the student during initial history and physical or bedside rounds?

If no:

  • Was an attending physically present with the student?
    • If yes: This is a billable note. The student should write the note with the attending as cosigner and attending attestation. The attending should use this attestation:
      I was physically present with the medical student and patient, having personally performed/re-performed the physical exam and medical decision-making activities for the service. I verify that the history, physical exam and medical decision-making as documented in the note by the medical student are accurate except…
    • If no: This is not a billable note. The student must write a separate “Medical Student H+P Note” or “Medical Student Progress Note.”

If yes: This is a billable note. To proceed:

  • The student should write an “H&P Note” or a “Medicine Inpt Progress Note.”
  • The resident and attending are cosigners. First, the resident reviews the note and provides feedback.
  • Both resident and attending attestation are required. The attending should use the following attestation:
    My resident was physically present with the medical student and patient, and I have personally performed/re-performed the physical exam and medical decision-making activities for the service. I verify that the history, physical exam and medical decision-making as documented in the note by the medical student are accurate except…

With Questions

With questions on student billable notes, email Dr. Nicholas Duca at nduca@pennstatehealth.psu.edu or Dr. Eileen Moser at emoser1@pennstatehealth.psu.edu.