Wiki Medical Student Documentation Requirement

[vclementcma@gmail.com]

In the medical student documentation, when the physician adds his/her Attestation/Attending Note with the statement "ATTESTATION by physician Name, date and time, (Verified)" at the beginning of their note, does the document still need to contain a signature line at the bottom of the note?

 

[loveshoes026]

Good morning!
I found some information for you but this is coming from a VHA directive, which from my understanding is a lot more stringent and may not be applicable in every setting and for every payer. I'd be curious to see what others respond. Hopefully this helps!

(a) Documentation Standards: The attending/teaching physician must document that they personally performed (or re-performed) the physical exam and medical decision making activities of the E/M service being billed and must verify any student documentation in the medical record. The medical student note must include an addendum or additional note entry in the medical record by a responsible physician attending to meet documentation and billing standards. An additional addendum by a resident may be necessary to adequately reflect his/her role in the care of the patient. The documentation from the attending physician may be accomplished by one of two methods, addendum or additional note referencing the medical student documentation. The addendum or additional note authored by the responsible physician attending must include and address the required following items:
1. Presence: A statement should be made about whether the attending was present during the student’s examination or if the attending re-performed the history and examination at a later point in time.
2. Performance: The attending physician must document whether they performed or re-performed the examination documented in the student’s write up.
Sample language: I hereby attest to the accuracy of the student’s note as to history, physical examination, and medical decision making with any exceptions or corrections noted. I was present for the medical student history taking and examination. I independently performed or re-performed the history taking, physical examination, and medical decision making.
”NOTE: The teaching physician’s note or addendum must provide appropriate and accurate documentation of the clinical encounter, clinical thinking, presumed diagnosis and treatment plan. A co-signature alone by the teaching practitioner of a note entered by a trainee is not sufficient for billing or supervision purposes. As is true with any individual writing in a medical record, medical students are not permitted to write a note and change the author to the teaching physician or resident physician. Resident physicians may add an addendum to the student note thus contributing to the medical record but ultimately it is only the attending physician who can cosign and provide attestation of the medical student’s work.

1. The responsible physician attending must be identified in the medical record in the documentation of each encounter and this may be accomplished by co-signature and an appropriate addendum or note. The responsible physician attending is the primary physician provider of record for billing purposes. The identification of the responsible physician attending, while necessary, is not sufficient for billing the encounter
2. The responsible physician attending must create an independent note OR an addendum to a note initiated by a medical student for the encounter to be billable in addition to co-signature. The responsible physician attending’s note or addendum must provide appropriate documentation of the clinical encounter and clinical thinking. A co-signature by the supervising practitioner of a note entered by a medical student alone is not sufficient for billing purposes.