From Brett Leggett, MD
New CMS requirements allow for use of a complete medical student note to support billing as long as strict requirements are met. A resident and/or attending must be physically present during the performance of the student’s history and exam, and the history and exam must be re-performed by the attending before validating the student’s documented findings. For the medical teams, medical students are expected to forward their notes to a resident for attestation, who will then forward the note to the attending.
If a student has authored a note and the requirements above have not been met, the attending must write their own note. Below is a screenshot of the new attestation section that will be found in the H&P, Consult, and all medical service progress notes starting Jan 28th. The attestation section for medical student authorship has two required components (“PRESENT” and “VALIDATE”), while the resident authorship section closely resembles the current attestation section: