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Implementation of Changes to Medical Student Documentation at Duke University Health System: Balancing Education With Service.

  • Gagliardi, Jane P1
  • Bonanno, Brian2
  • McPeek Hinz, Eugenia R3
  • Musser, R Clayton4
  • Knudsen, Nancy W5
  • Palko, Michael6
  • McNair, Felice7
  • Lee, Hui-Jie8
  • Clay, Alison S9
  • 1 J.P. Gagliardi is associate professor, Department of Medicine and Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.
  • 2 B. Bonanno is associate vice president for compliance, privacy, security, and integrity, Private Diagnostic Clinic, Durham, North Carolina.
  • 3 E.R. McPeek Hinz is associate chief medical information officer, Duke University Health System, Durham, North Carolina.
  • 4 R.C. Musser is assistant professor, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
  • 5 N.W. Knudsen is professor, Department of Anesthesiology, and assistant dean for the learning environment, Duke University School of Medicine, Durham, North Carolina.
  • 6 M. Palko is instructional designer and informatics educator, Duke University Health System, Durham, North Carolina.
  • 7 F. McNair is compliance auditor, Duke University Health System, Durham, North Carolina.
  • 8 H.-J. Lee is senior biostatistician, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina.
  • 9 A.S. Clay is assistant professor, Department of Surgery and Department of Medicine, and assistant dean for clinical education, Duke University School of Medicine, Durham, North Carolina; ORCID:
Published Article
Academic medicine : journal of the Association of American Medical Colleges
Publication Date
Jun 01, 2021
DOI: 10.1097/ACM.0000000000003729
PMID: 32909999


When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships. In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2018 to August 2019, locations and types of student-involved services (student-faculty or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed before August 2018, it was not possible to compare with prior student experiences. In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents, and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (> 90%) viewed their documentation as having a moderate or high impact on patient care. Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service. Copyright © 2020 by the Association of American Medical Colleges.

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