June 2018

Implementing the Revised Student Documentation Guidelines from CMS

New guidelines from Centers for Medicare and Medicaid Services (CMS) for the use of student documentation in the medical record were released in February 2018. The revised guidelines allow teaching physicians to edit/amend/use the student note on E/M services and not have to write an additional note to bill for the visit. Now that student documentation is allowed for billing purposes, the unnecessary administrative burden on teaching physicians of rewriting the entire note is removed. The previous language hindered student learning and caused an unnecessary paperwork burden on preceptors.

This change came about after an interprofessional, interdisciplinary team approached CMS with a request to change the restrictions on the use of the student note. CMS supported the request to change the requirements to allow use of the verified student note.

You may want to review the updated requirements for the use of student notes with your entire clinic staff to ensure that everyone is aware of these changes. Sample attestation language can be found in this FAQ document

More About Electronic Health Record (EHR) Use

Visit the EHR and Health Informatics section for more tips on teaching and monitoring the student use of electronic health records.