Medical Student Documentation

As we welcome a new incoming class of medical students, it is a good time to review the rules surrounding medical student documentation in the E/M encounter.

A supervising faculty physician or a resident must be physically present at all times, when a medical student performs any portion of a patient examination. All billable services must be performed by the attending physician or properly supervised resident physician. This means that the physician or resident must re-perform any portion of the exam that was done by a medical student. The physician/resident is also responsible to perform the medical decision-making component of the exam. Medical students may document the encounter note, though the supervising physician must review and edit as appropriate and must verify that note by attesting to having done this.

If you have questions about this or any other documentation/ coding issues, please feel free to contact the Compliance Advisory Services department at 951-827-4672.