Medical and Other Health Care Student Documentation

Category: Compliance

Date: July 1, 1996

Reviewed/Revised: April 2013

Purpose

To identify that portion of medical student documentation that may be used by the teaching physician for billing purposes.

Policy

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 social history (“PFSH”). The teaching physician may NOT reference a medical student’s documentation of physical exam findings or medical decision-making in his/her personal note. The teaching physician must verify and re-document the history of present illness (“HPI”), as well as perform and re-document the physical exam and medical decision-making activities of the visit service. This rule also applies to documentation by other health care students including, but not limited to, physician assistant students and nurse practitioner students.