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Superior Student Chart Notes Challenge Medicare Documentation Policies


Section Editor(s): Hemmer, Paul MD


Correspondence: Richard Usatine, MD, Associate Dean of Medical Education, Florida State University College of Medicine, Call and Stadium, Tallahassee, FL 32306-4300; e-mail: 〈〉.

Special thanks to Donna Azizi for her volunteer efforts in collecting data for this study. We wish her well in her plans to go to medical school.

Restrictive Medicare chart documentation policies threaten the quality of medical student education by limiting the use of students' chart notes in the medical record. According to the latest Association of American Medical Colleges (AAMC) tutorial “Medicare Teaching Physician Documentation Instructions,” teaching physicians may only refer to and use student documentation of the “review of systems and past family and social history.”1 In the ambulatory setting, these aspects represent a small part of the chart note, especially on a follow-up visit. Medicare suggests that the presence of a student note in lieu of a full preceptor note indicates that preceptors are committing fraud by charging for care that they are not actually delivering.

However, it is essential for all medical students to learn to become skilled at charting. The 1998 report of the AAMC Medical School Objectives Project states that medical students must have demonstrated, to the satisfaction of the faculty, “the ability to communicate effectively, both orally and in writing, with patients, patients' families, colleagues, and others” before graduation from medical school.2 Written communication between colleagues is essentially the medical record. If student charting is no longer valued or required we run the risk of not fulfilling this important educational objective for physicians-in-training.

Student charting is also a major time-saving method for preceptors.3 At a time when productivity demands on community preceptors is at an all-time high, decreasing students' contributions to patient care documentation may lead to the loss of valuable preceptor time spent duplicating or replacing students' charting efforts. Given that most medical schools do not compensate community preceptors for their teaching time,4 the preceptors' time lost meeting these government regulations may threaten preceptor recruitment and retention in the future.

In one review, the authors give the opinion that the safest, least complicated way to adhere to the HCFA guidelines is to have no student documentation in any patient record. These authors recommend that preceptors not rely on student notes even in those encounters in which Medicare was not the third-party payer.5

Fields et al. surveyed core clerkship directors to see how they perceived these guidelines were affecting participation of university- and community-based preceptors in clinical clerkships.6 These core clerkship directors expressed concerns that the Medicare guidelines had resulted in a number of negative consequences, including loss of student independence and active participation in the patient care environment, changing balance between education and service, loss of preceptors, decreased morale, and decreased quality of care for patients.6 Following implementation of the Medicare guidelines in the inpatient setting, Fihn et al. found that physicians reported a large increase in overall time spent attending on the wards, with a decrease in time spent teaching. This study relied on self-reported perception, as did the study of clerkship directors.7 We decided to do a true observational study of the outpatient setting.

Our hypothesis is that medical students' chart notes are as good as or better than preceptors' notes. This means that not allowing students' notes to be used as valid documentation may have a negative effect on the quality of the patients' charts. We wanted to see whether referring to or relying on a student's chart note would be Medicare fraud.

We designed the study to evaluate the quality of students' notes compared with preceptors' notes in the outpatient setting. We decided to observe the preceptors to determine whether they would review the students' notes and see the patients when students' notes were included in charts. The ultimate goal was to provide real observational data to be used to inform future policymakers to create rational Medicare chart documentation guidelines, ones that support high-quality medical education, patient care, and documentation.

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We recruited family medicine preceptors who were teaching third-year family medicine clerkship students in their offices. All the available preceptors were contacted by e-mail and phone, and only three preceptors agreed to be observed. Each preceptor was observed on two different days. Six medical students working with these preceptors agreed to be observed, and 31 patient encounters and charts were evaluated.

Observation and chart review criteria were developed. Observational method was based on the methods used to study “exemplary preceptors.”3 To protect confidentiality, we do not report the preceptors' names, and did not record the types of medical insurance carried by the patients.

Two medical student observers used stopwatches to time each preceptor on a day when they were working with third-year medical students in an outpatient setting. An entire encounter was defined as the cumulative time spent by the preceptor and student working with one patient. We used an observational instrument to document the preceptors' times with students and patients, and a second instrument to document preceptor—patient interactions without students present.3

The chart notes from the encounters observed were evaluated at the end of the day and scored using explicit criteria developed by the study team. Two of three team members reviewed all completed chart notes written by student—preceptor teams and preceptors alone for 20 items including legibility, comprehensibility, completeness, and preceptors' changes. Chart note legibility was assessed by reading the first ten words in the subjective part of the note (following the chief complaint). General comprehension was assessed subjectively by the investigators using a three-point scale in which 1 = poor, 2 = average, 3 = high comprehensibility. Completeness of the note was assessed using a number of parameters for each section of the SOAP note. (SOAP is a commonly used acronym in medical documentation in which the letters refer to the following portions of the chart note: Subjective, Objective, Assessment, and Plan.)

Finally, preceptors' changes to the students' notes were assessed. Did the preceptors read and contribute to the students' chart notes? How many additions, deletions, and corrections were made? Where corrections were made? Were the corrections made in the middle or the end of the note? Or was the note totally rewritten?

Means, standard deviations, and independent-sample t-tests were performed using standard statistical software. Significance level was set at p < 0.5.

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During the summer of 2000, 31 patient encounters and charts were evaluated. The encounters were relatively evenly divided among the three preceptors, with 12, ten, and nine encounters for the individual preceptors evaluated. See Table 1 for a comparison of preceptor times per patient with and without students present.



The students' chart notes were all rated at the top of the legibility scale by each of the three separate reviewers (9 to 10, with means of 9.8 to 10). Three is the best score on the comprehension scale and 10 is the best score on the legibility scale. The preceptors' notes were more varied in their legibility, and their mean scores fell in the middle of the legibility range (range of 4 to 10 and means of 4.5 to 8.4). The general comprehension mean rating was far higher for the students, from 2.9 to 3 (range 2 to 3) and in the preceptors' notes ranged from 1 to 3, with a mean of 1 to 2.9 for the three observers.

All of the students' notes were read and signed by the preceptors. Twenty-one percent of the notes had one addition made and 26% had three to four additions made. There were no complete deletions, but 11% of the chart notes had some type of correction performed by the preceptor. All of the corrections and additions that were made were recorded within the body of the student note.

The scores for completeness are summarized below:



Every student—preceptor note (note written by a student and reviewed by a preceptor) included a blood pressure measurement and documentation of the physical exam, whereas only 92% of the preceptors' notes documented these areas. Student—preceptor notes received superior scores in four out of seven completeness categories and were equal in one category. The student—preceptor notes were far better at documenting follow-up plans and health education. The only area in which student—preceptor notes were statistically less complete was in explaining the diagnosis or differential diagnosis (42% versus 58%).

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The preceptor saved 3.3 minutes per patient when a medical student was involved in patient care, and much of the time saved was from student charting. This gave the preceptor time for teaching. The patient received on average over nine minutes of direct time and attention from the preceptor when the student was involved. Although this was less than the average of 12.9 minutes measured for the preceptor alone, the patient received more total time from the student—preceptor team than from the preceptor alone (24.9 minutes versus 12.9 minutes).

The students' notes were of an overall higher quality than the notes of the preceptors alone. Students' notes were on average more legible and comprehensible than preceptors' notes. Overall, the students' notes were more complete than those written by preceptors alone. Students' notes received superior scores in four of seven completeness categories.

The one area in which the preceptors' notes were rated more highly on average was naming the diagnosis or listing a differential diagnosis. While physicians' handwriting and completeness of notes do deteriorate over time under the pressure to see more patients in less time and complete enormous quantities of ever-increasing paperwork, the preceptor still has greater knowledge of patient assessment and diagnosis. This is an area in which the preceptors may help students learn if they have the time to teach the students. This precious teaching time needs to be preserved to keep up the quality of medical education in our country. The paperwork demands of the current Medicare guidelines threaten this teaching time.

In this study, the three preceptors did rely on the reviewed and signed student notes for the sole documentation in the chart and did see all the patients. In other clinical settings, preceptors often spend their time copying over students' notes or writing their own notes to meet Medicare guidelines. The preceptors' time lost charting (an average of 4 minutes/patient in our study) may cut down on valuable patient contact time or teaching time. While it is essential for preceptors to see the patients previously evaluated by the students to assure high quality of care and teaching, a preceptor's note in the patient's chart does not prove that the preceptor saw the patient.

My informal discussions with medical students suggest that the Medicare guidelines lead students to feel undervalued and discourage them from practicing documentation skills. The students want to contribute to patient care and documentation. If the student note does not count, then the student has less of an incentive to write a note and the preceptor may not give feedback to the student on documentation. While the students' notes in this study were far more legible, readable, and complete than the preceptors' notes, the preceptors in our study did edit the notes to provide needed feedback to the students as well as to ensure quality control for the charts.

Limitations of this study include the small sample size and the fact that the students and preceptors knew that they were being watched. This is because it is hard to get community preceptors to allow outside observers to time their patient care and teaching. While a larger chart study could have been done without the observations, we felt that it was critical to correlate the patient care and teaching behaviors with the charting. My informal discussions with teaching physicians and medical students indicate that both parties believe that students' notes are in fact more legible, comprehensible, and complete than teaching physicians' notes. Even though the preceptors knew their charts were being reviewed and could have attempted to write better notes, the study data confirm this common belief held by most physicians and students.

One might claim that the preceptor participants reviewed all the notes and saw all the patients because they were being watched. However, these preceptors and their students claimed that this was their normal teaching practice during all practice sessions. While this small study is not generalizable to all teaching physicians in all locations across the country, it does give some insight into the issues that surround ambulatory teaching, charting, and practice.

This study and a previous study indicate that the major time saving that a student brings to the clinical setting is his or her assistance in chart documentation.3 If followed, the Medicare guidelines appear punitive to the teaching physicians by taking away the assistance that students provide by charting. If the guidelines are not followed, the community preceptor may be at risk for being charged and convicted of billing fraud.5 Neither alternative is acceptable at a time when physicians are under great pressure to see more patients in less time and to spend more time with increasing paperwork.

Recruiting and retaining community preceptors continues to be difficult, and community teaching remains an underfunded aspect of medical education. We cannot afford to lose our community preceptors at a time when academic health centers are not equipped to provide ambulatory training to the large numbers of medical students throughout our nation. If we are going to keep our vastly unpaid or underpaid community preceptors involved in volunteer student teaching, we need to re-examine the Medicare documentation guidelines.

The Medicare policy was written to prevent billing fraud. While teaching physicians need to see student-evaluated patients for quality of care and teaching purposes, refusing to allow students' notes to stand as valid documentation in the medical record does not accomplish this goal. The current Medicare guidelines threaten the quality of medical education, threaten the morale of our students and community teachers, diminish the quality of patient documentation, and do not accomplish the government goal of preventing fraud.

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1. Medicare's Teaching Physician Documentation Instructions. Washington, DC: Association of American Medical Colleges, 1998.
2. The Medical School Objectives Writing Group. Learning Objectives for Medical School Education—Guidelines for Medical Schools: Report I of the Medical School Objectives Project. Acad Med. 1999;74:13–8.
3. Usatine RP, Tremoulet PT, Irby D. Time-efficient preceptors in ambulatory care settings. Acad Med. 2000;75:639–42.
4. Fields S, Usatine R, Stearns J, Toffler W, Vinson D. The utilization and compensation of community preceptors in U.S. medical schools. Acad Med. 1998;73:95–7.
5. Chappelle KG, Blanchard SH, Ramirez-Williams MF, Fields SA. Off the charts: teaching students in compliance with HCFA guidelines. Fam Pract Manage. 2000;7(5):37–41.
6. Fields SA, Morrison E, Yoder E, et al. Clerkship directors' perceptions of the impact of Medicare documentation guidelines. Fam Med. 2002.
7. Fihn SD, Schleyer AM, Kelly-Hendrick H, Martin DB. Effects of the revised Medicare evaluation and management guidelines on inpatient teaching. J Gen Intern Med. 2000;15:451–65.
© 2002 by the Association of American Medical Colleges