J.P. Gagliardi is associate professor, Department of Medicine and Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.
B. Bonanno is associate vice president for compliance, privacy, security, and integrity, Private Diagnostic Clinic, Durham, North Carolina.
Acad Med. 2021 Jun 1;96(6):900-905. doi: 10.1097/ACM.0000000000003729.
When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships.
In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2018 to August 2019, locations and types of student-involved services (student-faculty or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed before August 2018, it was not possible to compare with prior student experiences.
In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents, and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (> 90%) viewed their documentation as having a moderate or high impact on patient care.
Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service.
当医疗保险和医疗补助服务中心 (CMS) 改变了对医学生文件记录的政策后，在适当监督下，学生现在可以在电子健康记录 (EHR) 中记录病史、体检和医疗决策，以便计费。由于文件记录是医学生的核心委托专业活动，作者试图评估学生在实习期间的文件记录和反馈机会。
2018 年 2 月，成立了一个多学科工作组，在杜克大学卫生系统实施学生文件记录，包括培训学员和监督人员、跟踪 EHR 使用情况以及执行 CMS 合规性。从 2018 年 8 月到 2019 年 8 月，使用从证明声明中提取的计费数据来跟踪学生参与服务的地点和类型（学生-教员或学生-住院医师-教员）。学生实习结束评估包括文件记录机会和反馈接收。由于 2018 年 8 月之前不允许文件记录，因此无法与之前的学生经验进行比较。
在该学年的上半年，有 6972 次患者就诊被计费为学生参与的服务，52%（n=3612）在住院环境中，47%（n=3257）在门诊环境中。大多数（74%）住院就诊还涉及住院医师，大多数（92%）门诊就诊仅为学生带教医生。大约 90%的学生表示在整个实习期间都有机会在 EHR 中记录文件，但手术和妇产科等以程序为基础的实习除外。在使用评估和管理编码的服务中，记录机会和反馈机会的存在率都超过 85%。大多数学生（>90%）认为他们的文件记录对患者护理有中等或高度影响。
学生文件记录的变更成功实施和采用；这些变更既满足了卫生系统的合规性和教育需求，又没有导致滥用学生工作为服务。
