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Guidelines and Workflow for Medical Student and Physician Assistant Student Billable Notes in Patient Charts

Student documentation includes 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.

Departments across Penn State Health 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.

The following table shows the differences in documentation policies depending on the supervising provider (i.e attending physician, resident physician, or advanced practice provider). Please note the differences in physician vs. APP requirements for verifications of specific components of the history and physical exam.

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Working With Student Billable Notes: Guidelines

  • To satisfy the physical presence requirement of the CMS policy, the attending (or supervising advanced practice provider) 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:
    • A. The attending, APP or resident is physically present while the student performs the history and physical examination, or
    • B. The attending, APP or resident re-performs and verifies the history and exam with the student present.
  • There is one resident/intern attestation (see resident/intern workflow guide).
  • There are two attending/supervising APP attestations based on the resident’s presence (see attending workflow guide).
  • Residents, attendings and supervising APPs 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. 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/supervising APPs

Residents, attendings and supervising APPs 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.

Workflow

Student Workflow Expand answer

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

If no: This is not a billable note. Open a “medical student” titled note.

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

  • Open the preferred note for the service line (do not use a medical student titled note)
  • Add this text under the note title:
    This note was written by a medical student or APP 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/supervising APP 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/supervising APP physically present with the student?
    • If yes: This is a billable note. The student should write the note with the attending/supervising APP as cosigner and attending/supervising APP attestation. No resident attestation is required.
    • If no: This is not a billable note. The student must write a separate “medical student” titled note.

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

  • The student should write the preferred note template for the service line.
  • 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/PA) student, having personally performed/re-performed the physical exam, and medical decision-making. I verify that the (medical/PA) student’s note is accurate and reflects the services provided except …
Attending/supervising APP 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/supervising APP physically present with the student?
    • If yes: This is a billable note. The student should write the note with the attending/supervising APP as cosigner and attending attestation. The attending/supervising APP should use this attestation:

      Attending attestation:

      I was physically present with the (medical/PA) 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/PA) student are accurate except…

      APP attestation:

      I was physically present with the (medical/PA) 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/PA) student are accurate except…
    • If no: This is not a billable note. The student must write a separate ”medical student” titled note.

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

  • The student should use the preferred note template for the service line.
  • 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/PA) student at the encounter, 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/PA) student are accurate except…

Additional Notes

  1. Medical Student and PA Student non-billable notes:
    Medical students and PA students may document their notes in the EHR without the physical presence of the attending, resident, or APP, but these notes may not be used for billing purposes.  However, as per CMS guidelines, physicians of record as well as residents may refer to the nonbillable medical student note for documentation of the Review of Systems, Past Medical History, Family History, or Social History. Attending physicians or residents must personally document all other components of a History & Physical, including the Chief Complaint, History of Present Illness, Physical Examination, Assessment and Plan in a separate electronic note in order to meet CMS guidelines and to ensure accurate billing and coding.  As per CMS guidelines, APPs may not refer to the student note as documentation of the Review of Systems, Past Medical History, Family History or Social History but rather must document all components of their note in the EHR. The nonbillable student note is entered in the EHR system with the title of “Medical Student Note” or “PA Student Note” respectively. Final signature of the nonbillable student note may be from the supervising attending or resident or APP as determined by the respective chair in each respective department.
  2. Students may not serve as scribes.
  3. Students may complete the Discharge Instructions and Discharge Summary.
  4. Students rotating outside of the Penn State Health system shall follow the policies and procedures for medical student documentation of the host facility.
  5. Publishing Status. Medical student notes shall be viewable to all after completion by the student and before final signing.

View Penn State College of Medicine medical student handbook.

Approvals Expand answer

Authorized: Eileen Moser, MD. Associate for Medical Education
Approved: Committee on Undergraduate Medical Education

Date reviewed: November 21, 2024

Most recent changes: Updated policy to be congruent with CMS changes that permit medical student and PA student billable notes. Unifying policy to cover MD and PA programs.

Revision history

Date approved: November 21, 2024

Date published: November 21, 2024

Policy’s initial date: August 20, 2012

Content reviewers and contributors

  • Vice Dean for Educational Affairs
  • Chief Medical Information Officer, Penn State Health
  • Associate Dean for Medical Education, Hershey Campus
  • Assistant Dean and Program Director Physician Assistant Program
  • Compliance Officer Penn State Health