Student notes and patient records: verify, don’t rewrite

Medicare: verify instead of rewriting

In its calendar year 2020 physician fee schedule, CMS finalized a broad change to documentation. Physicians, physician assistants and advanced practice registered nurses may review and verify (sign and date) notes already in the record, rather than re-documenting them. The people who may make those notes include residents, nurses, medical students, and PA and APRN students.

The rule applies to Medicare-covered professional services paid under the physician fee schedule, and the clinician who furnishes and bills the service is the one who verifies. Commercial plans and Medicaid programs set their own documentation rules, which your practice’s billing team knows.

What that saves you

Before 2020, preceptors often wrote their own note on top of the student’s. Now a student can draft the note, you review it, correct anything that needs it, and sign. For a preceptor with a student on every clinic day, that is time back on every visit, and the student builds one of the most important skills in practice: clear, accurate documentation.

A note that reads well

Whoever drafts it, a finished note with a student usually shows:

• That a student took part, and which parts of the visit they led.
• That you supervised the encounter and saw the patient.
• Your agreement with the assessment and plan, or what you changed.
• Your signature and date, verifying the record.

HIPAA: training is part of health care operations

HIPAA’s definition of health care operations, in 45 CFR 164.501, includes conducting training programs in which students, trainees or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers. Training students is part of a practice’s ordinary work under HIPAA, so a supervised student works with patient information as part of that training.

HHS has also said that practices can shape their minimum necessary policies to give trainees access to the patient information they need, including entire medical records.

Mental health training

Psychotherapy notes have their own rules under HIPAA. For supervised training, HIPAA includes a provision for a covered entity’s own training programs in which students or trainees in mental health learn, under supervision, to practice or improve their skills in group, joint, family or individual counseling. That is how psychiatric, counseling and social work students learn from the full range of their supervisor’s work.

Introducing the student to patients

Patients are used to students in clinics. A short, confident introduction works best: who the student is, what they will do, and that you are there throughout. Follow your practice’s consent process, and most patients are glad to help a future clinician learn.

Setting up student access

Many practices give a student their own login to the records system, with a role suited to students, so their drafts are clearly marked and every entry is attributed. Ask your practice manager or IT contact before the first day, and the student can start documenting from day one.

Coaching a student’s notes

Documentation is one of the most practical skills a student takes from a rotation. A few habits help: a clear chief complaint, a focused history and examination, an assessment that names the reasoning, and a plan the next clinician can follow. Reviewing one or two of the student’s notes together each week, with one specific suggestion, improves them quickly.

Notes for telehealth visits

For a video visit, the note also records that the visit was by telehealth, the patient’s location, and who took part, including the student. Your practice’s telehealth template usually has these fields already.

Introducing the student in the record

Many practices add a line to each student-assisted note, such as “seen with nurse practitioner student [name]; I saw and examined the patient and agree with the assessment and plan”, adjusted to what happened at the visit. Your practice’s template may already include a student attestation; ask your practice manager or billing team which wording they use.

Students and the care team

A student who documents well becomes a real help to the whole care team. Clear notes, accurate medication lists and well-written patient instructions save time for nurses, medical assistants and the next clinician to see the patient. Many preceptors make documentation an explicit goal for the second half of a rotation, and students value the practice: clear documentation is one of the skills employers notice first.

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