Play it safe when documenting E/M services: Keep your medical students' documentation out of patient chart notes.
Fam Pract Manag. 2000 May;7(5):37-41.
Office-based family physicians have had an increasingly important role in medical student education, especially since the late 1980s when, as a result of nationwide curriculum reform, students began working with community preceptors as early as their first term of medical school. It seems ironic that just when community physicians are becoming indispensable to medical education, time constraints, multiple expectations of third-party payers and other managed care hassles may threaten their willingness to teach.
At the Oregon Health Sciences University, we rely on literally hundreds of physicians in and around Portland to precept our medical students and residents. At least one talented community-based physician has dropped out of our program because of headaches complying with the Health Care Financing Administration's (HCFA) documentation guidelines for teaching physicians. And more may follow if interpreting the guidelines doesn't get easier.
In this article, we'll show you how family physicians can integrate medical students into their practices without relying on them for documentation. This will allow you to bill Medicare for services that involve students without increasing your risk of HCFA violations.
Teaching physicians who don't understand the extent to which medical students can document a Medicare patient's visit risk violating HCFA regulations.
The safest, least frustrating way to comply with HCFA regulations is not to include any student notes in your patient records.
You can provide plenty of learning opportunities for medical students by thinking “outside the box” about how students can contribute to a practice and its patients.
Do your own documentation
Historically, medical students have been taught proper documentation skills by writing or dictating patient chart notes for the clinical preceptor. It helps reduce paperwork for the time-crunched preceptor and gives students hands-on experience with documentation. However, now that chart notes are used to support the billing codes submitted to HCFA, relying on medical students to document Medicare patients' visits may cause physicians serious problems. That's because HCFA requires teaching physicians to supervise and personally document the key portions of each patient visit. According to the Association of American Medical Colleges (AAMC), who worked with HCFA to interpret the guidelines, you cannot submit billing that relies on medical student documentation of any portion of the patient visit except for the review of systems and past, family and social history. (For more information, see the “AAMC interpretation of HCFA guidelines.”)
All of this may sound straightforward, but there's been much debate and confusion in the education community about the guidelines and their impact on the training of medical students (see “Common questions about HCFA guidelines”). At this point it's not even certain that the guidelines and the AAMC's interpretation of them are entirely applicable for community preceptors. And while the guidelines seem to apply only to visits with Medicare patients, you should know that some states have also adopted the HCFA guidelines for Medicaid patients. So, it's entirely possible that in the event of a government audit of your practice, these records could also be subject to scrutiny.
AAMC interpretation of HCFA guidelines
The Health Care Financing Administration's (HCFA) guidelines apparently allow medical students and other learners to document only the past, family and social history (PFSH) and the review of systems (ROS). All other key elements of the visit must be personally documented by the teaching physician. Organizations concerned with how HCFA guidelines affect medical student and resident education, such as the Association of American Medical Colleges (AAMC) and the Society of Teachers of Family Medicine, continue to question the appropriateness and the interpretation of these guidelines. The following is an excerpt from the AAMC's tutorial “Medicare's Teaching Physician Documentation Instructions”:
“The only documentation by medical students that may be used by the teaching physician is their documentation of the review of systems (ROS) and past, family and social history (PFSH). The teaching physician may NOT refer to a medical student's documentation of physical exam finding or medical decision making in his/her personal note. The teaching physician must verify and re-document the history of present illness as well as perform and re-document the physical exam and medical decision-making activities of the visit service. This rule also applies to the documentation by other kinds of students, e.g., physician assistants and nurse practitioners.”
And this comes from a clarification memo sent from the AAMC Division of Health Care Affairs to the AAMC Group on Faculty Practice on Nov. 4, 1998:
“The teaching physician does NOT need to re-document the ROS or PFSH, if well-documented by a medical student, resident, nurse, vis a vis their note or standardized form. However, the teaching physician must perform and briefly re-state the history of present illness, since the rule states the teaching physician must provide a personal, summary note that demonstrates his/her personal service (work) in each of the major component activities of a visit service — i.e., history, exam and medical decision making — for all NEW patient visits.
“For an ESTABLISHED patient visit, such as a subsequent hospital or follow-up office visit, the teaching physician need only perform service and document his/her activity in TWO of the three areas, in accordance with the American Medical Association's Current Procedural Terminology. The physician may select from among the three areas of the visit to provide both personal service and documentation, depending upon patient need.
“The documentation by the teaching physician for history of present illness should be a brief statement (as little as one sentence) of why the patient is being seen by the physician on that particular occasion of service.”
As long as you personally document or re-document all key information according to the guidelines, including medical student dictations or notes along with your own chart notes probably won't increase the risk that you'll violate HCFA's guidelines. However, with dictation rates currently running 15 cents to 18 cents per line (approximately $3 per page), few practices can afford to have both students and physicians dictating notes on the same patients. In addition, because no one can predict what questions might arise in the event of an audit of your patient records, including your students' notes (which may not always be congruent with yours) in patients' charts adds an element of uncertainty that could be easily avoided.
For this reason, and to maintain consistency and prevent potential errors in documentation, it makes sense for you to write or dictate chart notes in the same manner for all of your patients — including those you see with medical students. Our recommendation for avoiding the confusion and concerns surrounding HCFA guidelines for teaching physicians is simply not to include medical student notes or dictations as part of your patient records.
Common questions about HCFA guidelines for teaching physicians
Do the same rules apply to teaching residents and students in community practices?
No. There are differences between the guidelines for teaching students — the subject of this article — and those for teaching residents. The Health Care Financing Administration's (HCFA) guidelines for precepting residents in community practices are complex, and they can vary depending on the residency program. We recommend that you contact your residency program director for information.
Do the HCFA guidelines apply to other payers?
HCFA is only concerned with regulating the billing practices of Medicare patients; however, some states have also adopted HCFA's guidelines for the care of Medicaid patients.
For what parts of the patient visit does HCFA require me to be present in the exam room?
The guidelines for medical students and residents differ. If a medical student participates in the visit, you must be present for the physical examination, medical decision making, treatment and procedures. It is your responsibility to document your involvement in the patient visit and bill appropriately on the basis of that involvement.
What portions of the history and exam must I repeat in order to be in compliance with HCFA?
You do not have to duplicate everything your medical student has accomplished with the patient, but you must repeat any portion of the exam directly related to the service being rendered. You must perform and briefly restate the history of present illness. You do not need to repeat past medical history, past social history, family history or review of systems.
Can HCFA sue me for letting my student do significant portions of exams or procedures?
No. HCFA cannot sue you for letting your medical student perform an exam or procedure under your direct supervision. Always ask the patient's permission before allowing a student to perform a procedure or sensitive exam.
Can my students write chart notes for non-Medicare patients?
If HCFA audits your practice for compliance, only the charts of your Medicare (and, depending on your state, possibly Medicaid) patients will be reviewed. However, in a busy practice where Medicare billing information is kept separate from medical charts, it would be easy for a student to accidentally write a note on a patient who actually was a Medicare or Medicaid patient. The safest, least complicated method to ensure compliance with HCFA's guidelines is not to include student notes in any patient charts.
Should I tell my students about these guidelines?
Definitely. Part of educating medical students is sharing with them the realities of all aspects of practicing medicine. It's important to explain to students why their notes are not being included in the actual patient record. Assure them that they are contributing even though their notes cannot be included.
Begin using a teaching file
It is still crucial that medical students learn to write or dictate appropriate chart notes in the context of patient care. We suggest that you continue to have students in your practice write full notes on patients, but instead of including them in patient charts, keep them in a separate teaching file. You can review and correct these notes, giving students feedback so that they can improve their skills. A teaching file also gives you material to assess student progress with documentation skills.
Admittedly, this process does require a bit more time than simply signing off on a student note, but it will help you as you write your own notes since you and your student will already have reviewed the details of the patient visit. Not using student notes in patient charts is an adjustment that needn't have a large impact on the amount of time or effort it takes to teach proper documentation skills. Just make sure you explain to your students what you're doing and why.
Expand students' responsibilities
If you are currently working with a medical student or would like to, we encourage you to consider alternative ways to make teaching a “value-added” activity in your practice. Students can gain time for you and contribute in many ways other than documenting patient visits. Although some preceptors are hesitant to involve students in projects or tasks that aren't directly related to seeing patients, as long as students have sufficient opportunities to practice and build on their interviewing and exam skills, you should feel free to involve them in activities not directly related to patient care. For the most part, students will appreciate opportunities to make real contributions not only to your patients, but to your practice. To help you start thinking “outside the box” about ways your students can assist you other than writing chart notes, consider our 12 suggestions.
Twelve “value-added” suggestions for working with medical students in your practice
Have students research, write or gather high-quality patient education materials on topics relevant to your patient population.
Have students contact community resources to find out what's available for patients in terms of alcohol treatment, marriage counseling, day care for the elderly, etc.
Have students serve as liaisons between your office and local resources to coordinate care for patients in your practice.
Ask your students to talk at length with patients you've been “meaning to talk to when you have time.” Your patients will benefit from the extra attention, and it will give students the opportunity to practice their interviewing skills.
If you are teaching a sufficiently advanced student, have the student tell you what he or she has learned from interviewing a patient before you enter the exam room.
Have students be responsible for gathering all ancillary information for each patient visit (e.g., test results, X-rays, etc.) so that you have everything you need when you enter the patient's room.
Have students assist patients by setting up referrals or coordinating physical therapy visits.
Have students perform literature searches when you need to research patient problems. 9. Have students perform chart or database reviews when you need to track particular patient information. Since most students are comfortable with computers today, they may even be able to offer ways to track data in your practice more effectively.
Have students make follow-up phone calls to patients concerning treatment plans, lab results, etc.
Have students conduct phone surveys of patients to address such quality assurance issues as “Have all of our elderly patients had a flu shot?”
Have your students conduct medication reviews with patients who take several different prescription drugs.
Yes, it's frustrating, but …
Working with medical students in your practice can take your focus off the day-to-day frustrations of medicine and help revive you. But the pressures you cope with daily may also threaten the quality of your teaching. Keep in mind that students just entering the medical profession haven't yet chosen a specialty, and your attitude can be the difference between showing them family practice at its best and turning them off completely.
If you're interested in or enthusiastic about teaching, don't allow worries about HCFA guidelines to keep you from working with medical students. Try expanding your students' traditional responsibilities so they can make real contributions to other areas of your practice and, at least for now, keep your students' documentation “off the charts.”
The Evolution of Courses in Professional Skills and Perspectives for Medical Students. Curry RH, Makoul G. Academic Medicine. 1998;73(1):10–13.
Medicare's Teaching Physician Documentation Instructions. Association of American Medical Colleges. 1998. Available at www.aamc.org/advocacy/issues/medicare/mtpdi.pdf.
Community-Based Faculty: Motivation and Rewards. Fulkerson PK, WangCheng R. Family Medicine. 1997;29(2):105–107.
Impact of Medical Student Teaching on Family Physicians' Use of Time. Vinson DC, Paden C, Devera-Sales A. Journal of Family Practice. 1996;42(3):243–249.
Kathryn Chappelle is director of curriculum development in the Department of Family Medicine at the Oregon Health Sciences University (OHSU) in Portland. Dr. Blanchard is director of the Family Medicine Subinternship in the Department of Family Medicine at OHSU. Miguel Ramirez-Williams is a faculty member in the Department of Family Medicine at OHSU. Dr. Fields is vice chair for clinical affairs in the Department of Family Medicine at OHSU.
We would like to acknowledge the thoughtful assistance of John W. Saultz, MD, chairman of the Oregon Health Sciences University Department of Family Medicine in formulating our response to this issue.
Copyright © 2000 by the American Academy of Family Physicians.
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