Avoiding Pitfalls While Implementing New Guidelines on Student Documentation
Authors: Todd Cassese, Melinda S. Sharkey, Amber T. Pincavage, Korry Schwanz, Jeanne M. Farnan
Journal: Annals of Internal Medicine (2019)

Ideas and Opinions5 February 2019Avoiding Pitfalls While Implementing New Guidelines on Student DocumentationTodd Cassese, MD, Melinda S. Sharkey, MD, Amber T. Pincavage, MD, Korry Schwanz, BA, and Jeanne M. Farnan, MD, MHPETodd Cassese, MDAlbert Einstein College of Medicine, Bronx, New York (T.C.)Search for more papers by this author, Melinda S. Sharkey, MDMontefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York (M.S.S.)Search for more papers by this author, Amber T. Pincavage, MDThe University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)Search for more papers by this author, Korry Schwanz, BAThe University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)Search for more papers by this author, and Jeanne M. Farnan, MD, MHPEThe University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-1924 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In February 2018, without fanfare, the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Claims Processing Manual to update policies about documentation by students in the medical record. The revision “allow[s] the teaching physician to verify in the medical record any [emphasis added] student documentation of components of [evaluation and management] services, rather than re-documenting the work” (1). Many observers predict that this change will improve medical student training: They will have more practice writing notes that teaching physicians will review and use to bill, and alleviating redocumentation burdens will free physician time for teaching (2). In addition, ...References1. Centers for Medicare and Medicaid Services; Department of Health and Human Services. E/M service documentation provided by students (manual update) transmittal 40682018. Updated 1 June 2018. Accessed at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10412.pdf on 7 November 2018. Google Scholar2. Power DV, Byerley JS, Steiner B. Policy change from the Centers for Medicare and Medicaid Services provides an opportunity to improve medical student education and recruit community preceptors. Acad Med. 2018;93:1448-9. [PMID: 29642106] doi:10.1097/ACM.0000000000002245 CrossrefMedlineGoogle Scholar3. Friedman E, Sainte M, Fallar R. Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Acad Med. 2010;85:1440-4. [PMID: 20736671] doi:10.1097/ACM.0b013e3181eac1e0 CrossrefMedlineGoogle Scholar4. Mintz M, Narvarte HJ, O'Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med. 2009;84:1698-704. [PMID: 19940575] doi:10.1097/ACM.0b013e3181bf9d45 CrossrefMedlineGoogle Scholar5. Association of American Medical Colleges. Medical school graduation questionnaire: 2015 all schools summary report. 2015. Accessed at www.aamc.org/download/440552/data/2015gqallschoolssummaryreport.pdf on 28 May 2018. Google Scholar Author, Article, and Disclosure InformationAffiliations: Albert Einstein College of Medicine, Bronx, New York (T.C.)Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York (M.S.S.)The University of Chicago Pritzker School of Medicine, Chicago, Illinois (A.T.P., K.S., J.M.F.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1924.Corresponding Author: Todd Cassese, MD, Assistant Dean for Clinical Sciences Education, Associate Professor of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461; e-mail, todd.[email protected]yu.edu.Current Author Addresses: Dr. Cassese: Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461.Dr. Sharkey: Department of Orthopaedic Surgery, Montefiore Medical Center, 3400 Bainbridge Avenue, 6th Floor, Bronx, NY 10467.Dr. Pincavage: Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 3051, Chicago, IL 60637.Ms. Schwanz: University of Chicago Pritzker School of Medicine, 924 East 57th Street, Suite 104, Chicago, IL 60609.Dr. Farnan: University of Chicago, 5841 South Maryland Avenue, MC 2007 AMB W216, Chicago, IL 60637.Author Contributions: Conception and design: T. Cassese, A.T. Pincavage, K. Schwanz, J.M. Farnan.Analysis and interpretation of the data: T. Cassese, J.M. Farnan.Drafting of the article: T. Cassese, M.S. Sharkey, A.T. Pincavage, K. Schwanz, J.M. Farnan.Critical revision of the article for important intellectual content: T. Cassese, M.S. Sharkey, A.T. Pincavage, K. Schwanz, J.M. Farnan.Final approval of the article: T. Cassese, M.S. Sharkey, A.T. Pincavage, K. Schwanz, J.M. Farnan.Administrative, technical, or logistic support: T. Cassese.This article was published at Annals.org on 15 January 2019. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byMedical Student and Trainee Notes in the Electronic Health Record EraImplementation of Changes to Medical Student Documentation at Duke University Health System: Balancing Education With ServiceImproved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing ChangesEarly Adoption of the CMS Rule Change for Medical Student Documentation 5 February 2019Volume 170, Issue 3Page: 193-194KeywordsHealth careInterleukinsMedical educationMedicarePatientsProblem solvingQuality of lifeReasoningSurgerySystematic reviews ePublished: 15 January 2019 Issue Published: 5 February 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...