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WRITE Preceptor Information

AACMC's Compliance Guidelines re. the Teaching of

Students Using an EHR

While this ONLY applies to Medicare patients, medical clinics and hospitals may decide the rule applies regardless of the payor:

Following Excerpts taken from the American Association of Medical Colleges (AAMC) Compliance Officers’ Forum—Compliance Advisory: Electronic Health Records in Academic Health Centers.

Topic 1: Medical Student Documentation; and CMS Guidelines.

Current recommendations: Medical Student Documentation Using EHRs from the AAMC


Medical students are learners. In no state are they given a license to practice medicine and therefore, they are never considered to be billing providers. Yet, an essential part of their education involves learning how to document patient care in the medical record. Without diminishing the educational value of medical student documentation, it also is important to understand the compliance risks that it may pose….


The movement to Electronic Health Records (EHRs) represents opportunities to improve patient care, eliminate issues related to legibility, increase communication, offer potential automated warnings, and structure medical information. It also presents significant challenges regarding the controls for authorship and authentication. The paper record shows trail of authorship in a tangible way, by ink, handwriting style and signature; creating a clear trail of authorship and authentication in an electronic record requires choices about the rules that will be used for anyone who adds information to a patient’s record.

While Medicare does not pay for the services of medical students, it allows the limited use of the medical student’s documentation to support a billable service.

Medicare has promulgated the following rules related to medical students:

1. Use of a Student’s Contributions to a Service

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

2. Student Documentation

Students may document services in the medical record; however, the teaching physician may only refer to the student’s documentation of an E/M service that is related to the ROS and /or PFSH. The teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and re-document the physical examination and the medical decision making activities of the services. Elements of medical student documentation that must be re-documented by a resident/provider include the history of the present illness, the physical exam, and medical decision making.

The Identified Risks in an Electronic Health Record

If the medical record does not clearly identify the original source of medical documentation it may allow inappropriate use of medical student documentation (inadvertently or intentionally) in support of a bill. Therefore, the creation of an audit trail alone is not sufficient to address this risk.

Intentional use of medical student documentation that is not ―re-documented by the teaching physician or resident (in accordance with Medicare rules) in support of a bill submitted to Medicare for Part B services may be considered by the Federal government to be fraud and abuse and may lead to allegations of False Claims Act violations.

Scribes--Using Medical Students as Scribes:Any policy on the use of scribes should consider that scribes may create substantial compliance risks.

CMS Guidelines on the use of Scribes

Many providers of Medicare services utilize scribes to assist with everyday documentation. There are various reasons why a provider may benefit from using a scribe, such as efficiency, legibility and the additional time to focus on patient care. 

The Centers for Medicare & Medicaid Services (CMS) offered the following guidance to contractors when reviewing evaluation and management services when documented by scribes in the medical record. 

  • If ancillary staff is present while the provider is gathering further information related to the patient's visit (e.g., the three key components), he/she may document (scribe) what is dictated and performed by the physician or NPP
  • The provider needs to review the information as it is written, documented, recorded or scribed. The provider also needs to write a notation that they reviewed the documentation for accuracy (add to it if supplemental information is needed) and sign his/her name.
  • The name of the scribe must be identified in the medical records. Note that although not required, the date of the signature should be noted.
  • Ancillary staff does not need to be employed by the physician (e.g., hospital employee) in order to fill the ‘scribe’ role

Example of Scribe Policy at Washington U St. Louis

Can you provide some examples of what is and is not appropriate under this policy?

Appropriate utilization of scribes:

  • A medical  student  who only writes down what the physician says during the assessment, observing and learning, but not touching the patient, and not documenting his/her own findings.

Inappropriate utilization of scribes:

  • A medical student evaluates the patient with the attending physician and the medical student documents the service.   The physician edits, corrects and signs the note.  This does not represent a scribed service.  


CMS (HCFA) Billing Guidelines

Current information is available on the CMS Web Page: Go to http://www.cms.hhs.gov/ and search key words “guidelines,” “teaching,” and “interns” for the Guidelines for Teaching Physicians, Interns, and Residents pdf. The following information is taken from the aforementioned pdf, page 3, at the above web site.

Possible Solution:

If it works at your site, it may be possible to have students document their notes using a Word document, which can be used as a discussion point to review student learning and to offer feedback.

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