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Student Documentation

  1. #1
    Default Student Documentation
    Medical Coding Books
    Does anyone know what a "student" not "resident" can document in a chart? Also if the student can document, what the doctor needs to document in the chart with the student? We are a general surgeon practice and have students and want to make sure our documentation is adequate.

  2. #2
    Evansville Indiana
    Default student
    I have always been told that a physician may only refer to a students documentation of the ROS and PFSH just like a nurse. According to the NGS Convention Students may document services in the medical record. Teaching physicians may only refer to student documentation that is related to the ROS or PFSH. The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note.

  3. #3
    Milwaukee WI
    Default Only ROS and PMFSH count
    The student can document anything. But only the ROS and PFMSH can count towards a billable service by the teaching physician.

    Also ... if the resident "co-signs" the student documentation that does NOT make it a resident note.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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