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Myth or fact? Teaching doctors must re-document student EHR work

Historically, teaching physicians were required to re-document medical students’ entries in a patient’s electronic health record (EHR). They don’t have to do that anymore.

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The AMA is spreading that message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative burdens that divert doctors’ attention from the delivery of patient care.

“Our primary focus is to clarify confusion around what regulations require,” said Christine Sinsky, MD, AMA vice president of professional satisfaction. 

The AMA’s debunking regulatory myths series is part of the AMA’s practice transformation efforts and provides physicians and their care teams with resources to reduce guesswork and administrative burdens so their focus can be on streamlining clinical workflow processes, improving patient outcomes and increasing physician satisfaction.

The series includes a webpage devoted to each regulatory myth, such as the one that physicians must re-document medical students’ entries in a patient’s EHR. In these articles, the myth is stated and debunked, and resources are provided to remove any lingering doubt that the myth isn’t true. More articles are being added regularly.

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Re-documentation requirement is history

The issue regarding physician re-documentation involves the process of medical students documenting evaluation and management (E/M) services, including patient history, physical exam and or medical decision-making, in patients’ electronic records.

“Historically, the teaching physician was required to re-document the medical student’s entries,” the “Debunking Regulatory Myths” item on this topic states. The Centers for Medicare & Medicaid Services (CMS), however, changed its policy in 2018.

The change—one the AMA advocated—was included in its Medicare Claims Processing Manual in a section discussing E/M-service documentation provided by students.

“Students may document services in the medical record,” CMS states in the manual. “However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision-making.

“The teaching physician must personally perform (or reperform) the physical exam and medical decision-making activities of the E/M service being billed but may verify any student documentation of them in the medical record, rather than re-documenting this work,” CMS adds.

CMS further amended this requirement in a Medicare Learning Network “Outreach and Education” resource with an additional sentence:

“If the teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E/M services, contractors shall consider this requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.”

Essentially, when teaching physicians “verify” student-supplied content in a medical record, they are attesting to its correctness and accuracy, while “re-documentation” requires that that physicians rewrite everything the student supplied.

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“In the context of an office visit, the teaching physician must always verify that the information collected and reported by the medical student or resident learner is accurate and complete,” said Kevin Taylor, MD, the AMA’s director of organizational transformation. “This requires their repeating the essential elements of the history of present illness (HPI) and physical exam (PE).

“In the past, they would re-document the essential elements of the HPI and PE. Now, they do not need to do this,” Dr. Taylor added. “They do, however, need to have a statement to the effect that they have reviewed the documentation and performed the essential elements of the HPI and PE, and agree with the documentation of the learner with any changes being made based on their personal review.”

For example, at Trinity Health, a 92-hospital, multistate Catholic health care delivery system, the following statement is used for supplying verification:

"I was physically present for the Evaluation and Management service provided. I agree with the student note and plan by [name of student] dated [date of note] which I have reviewed and edited where appropriate. I have performed the physical exam and made appropriate changes and have modified the medical decision making to reflect my own."

Send in your questions

Physicians and their care team members are invited to submit their queries about misinterpreted regulations to [email protected].