Are teaching physicians required to re-document the EHR work of students?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

Teaching physicians are not required to re-document medical students’ documentation of E/M components of a patient visit. Rather, they can simply verify these entries with a signature and date.¹

In February 2018, CMS documentation requirements changed, allowing teaching physicians to verify in the medical record student documentation of components of E/M services rather than re-documenting this work provided that the physician (1) is physically present and (2) personally performs (or re-performs) the physical exam and medical decision-making activities of the E/M service being billed.²

The use and verification of medical student notes can decrease physician documentation burden and improve the practical application of medical students’ education.

After changes to CMS documentation requirements went into effect, Stanford Children’s Health implemented medical student documentation. As a result, attending physicians’ interactions with student notes significantly increased from 4% of student notes reviewed to 84%. Further, students reported that implementation of this change enhanced their learning and made their notes more meaningful.³

Additionally, a January 2018 survey of preceptors revealed that approximately 92% believed that student documentation would save them time after clinic. Specifically, almost 50% (48.3%) reported this change would save them between 31-60 minutes per half-day session.⁴

• Medical Student Access to Electronic Health Records H-315.969
• CMS Documentation Guidelines for Teaching Physicians H-315.982

• CMS MLN Fact Sheet: Complying with Medicare Signature Requirements. Accessed November 2024.
• CMS MLN Matters Article: E/M Service Documentation Provided by Students. Accessed November 2024.
• CMS Claims Processing Manual: E/M Service Documentation Provided by Students. Accessed November 2024.
• AMA STEPS Forward® Playbook: Reducing Regulatory Burden. Accessed November 2024.
• AMA STEPS Forward Playbook: Simplified Outpatient Documentation and Coding. Accessed November 2024.

1. Centers for Medicare and Medicaid Services. Complying with Medicare Signature Requirements. MLN Fact Sheet; 2024. https://www.cms.gov/files/document/mln905364-complying-medicare-signature-requirements.pdf
2. Centers for Medicare & Medicaid Services. Pub 100-04 Medicare Claims Processing: Transmittal 4068. CMS Manual System. Change Request 10412; 2018. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4068CP.pdf
3. Stevens LA, Pageler NM, Hahn JS. Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes. Applied Clinical Informatics. 2021;12(03):582-588. doi:10.1055/s-0041-1731342
4. Society of Teachers of Family Medicine (STFM). FAQs: New E/M Service Documentation Provided by Students requirements included in Transmittal 4068; May 31, 2018. https://www.stfm.org/media/1360/new-em-service-documentation-provided_may2018.pdf

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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.