Medical Student EHR Documentation Policy Updated

UNC Health Care's "Medical Student Participation and Documentation in the EHR and the Use of Medical Student Notes by Physicians and Advanced Practice Providers" policy has been updated in PolicyStat.

Last year, CMS updated its policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work, provided certain requirements are met. This policy change applies only to E/M services and does not apply to procedure notes. The policy change is applicable only for a medical student and physician; the policy change does not apply to other students (e.g., physician assistant or nurse practitioner students) or other providers such as nurse practitioners or physician assistants.

Key implementation updates at UNC Health Care include an approved attestation in Epic@UNC.

For details, please review our updated medical student documentation policy and also the June 2018 edition of Professional Compliance’s POP News.
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