Are physicians required to redocument nonphysician entries in the patient record?

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.

Debunking the myth

The Centers for Medicare and Medicaid Services (CMS) permits physicians to verify, rather than redocument, the documentation of components of evaluation and management (E/M) services entered by others, when allowed by state law.^1,2 Likewise, teaching physicians may verify medical student documentation of E/M components with only a signature and date, with no need to redocument the work.³

Background

Ancillary staff, patients, or medical students may enter clinical information, such as the history of present illness (HPI), family and social histories, and review of systems, into the electronic health record (EHR). Historically, CMS required physicians to redocument these elements to receive payment and issued no guidance on the allowability of nonphysician entries into the medical record.

Changes in the 2019 Calendar Year Physician Fee Schedule modernized these policies. CMS clarified that any party may input these elements into the medical record, including patients through electronic questionnaires and clinical or ancillary staff.² In January 2021, Medicare documentation requirements were further streamlined: for visits billed based on content (as opposed to time), medical decision making (MDM)—not HPI, social or family history, review of systems, or physical exam (PE)—is the only component that determines the level of service (LOS).⁴ Still, relevant documentation must appear in the record to substantiate the LOS selected. For instance, billing a level four visit for an asthma exacerbation requires documentation of respiratory symptoms, elevated respiratory rate, auscultation findings, etc.

Similar reforms were implemented for teaching physicians in February 2018 when CMS authorized teaching physicians to verify medical student documentation of E/M components instead of redocumenting, provided they are physically present and personally perform (or re-perform) the physical exam and MDM associated with the E/M service being billed.⁵

Key takeaway

Reviewing and verifying ancillary staff, patient, and medical student documentation, rather than redocumenting, can reduce physician documentation burden and increase the time physicians spend caring for patients.

The 2019 CMS changes allow physicians to verify patient and staff supplied information for ambulatory visit documentation; there is no longer the requirement that physicians redocument these types of information.

In 2021, CMS changes allow physicians to determine the level of service based on either medical decision making (when billing by content) or by time. The bulk of the note (history and physical, patient histories, and PE) must still be present, and the content must support the severity of the E/M code that is selected based on medical decision making. 

Success story

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

AMA policy

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

Resources

• Federal Register Vol. 83, No. 226: Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019 (PDF). Accessed December 2025.
• July 2025 CMS MLN Fact Sheet (PDF): Complying with Medicare Signature Requirements. Accessed December 2025.
• 2018 CMS Claims Processing Manual (PDF): E/M Service Documentation Provided by Students. Accessed December 2025.
• 2024 AMA STEPS Forward® Playbook: Reducing Regulatory Burden. Accessed December 2025.
• 2025 AMA STEPS Forward Playbook: Simplified Outpatient Documentation and Coding. Accessed December 2025. 

References

1. Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS). 83 FR 59452.; 2018. Accessed December 5, 2025. https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf
2. Centers for Medicare & Medicaid Services (CMS). Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019.; 2018. Accessed December 5, 2025. https://www.federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
3. Centers for Medicare and Medicaid Services. Complying with Medicare Signature Requirements. MLN Fact Sheet; 2024. Accessed December 5, 2025. https://www.cms.gov/files/document/mln905364-complying-medicare-signature-requirements.pdf
4. Office of the Federal Register. Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2021. Vol CMS-1734-F.; 2020. Accessed December 5, 2025. https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1734-f  
5. Centers for Medicare & Medicaid Services. Pub 100-04 Medicare Claims Processing: Transmittal 4068. CMS Manual System. Change Request 10412; 2018. Accessed December 5, 2025. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4068CP.pdf

Debunking Regulatory Myths overview

Visit the overview page for information on additional myths. 

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.