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pje

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Posts: 1
Reply with quote  #1 

A psychiatrist on my team is asking if he can add to a medical student note and meet Medicare requirements for documentation. He wants to use the CC, HPI, etc and then add to the note at the end with any additional information or corrections, along with his own assessment and treatment plan. And he is asking if can copy the note and then edit the text to his liking and use this note as his note.

Is using a medical student note in these ways acceptable to meet Medicare regulations? I know resident notes can be attested to, but I believe medical student notes cannot, and I doubt that adding to a medical student note meets the Medicare standard.

kmrjpr

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Posts: 33
Reply with quote  #2 
If the student is NOT a resident, then they are no different than an MA and their documentation is limited to PFSH and ROS.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf

ShoshanaRuth

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Posts: 10
Reply with quote  #3 
If the medical student is being used as a scribe, they can't do the PFSH and ROS correct?  

Scribes are not allowed to participate in the clinical care of the patient per CMS.
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