A change in the Centers for Medicare and Medicaid Services (CMS) rules that govern medical student-written notes in medical records should make life easier for preceptors — and give clinical coordinators one more tool for recruiting them. The change that was made public in February by CMS was driven largely by advocacy from the Society of Teachers of Family Medicine (STFM). The revised guideline became effective March 5th and now states, “Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
Look for additional information on this initiative in an upcoming edition of the NC Family Physician magazine.