MD & DO Medical Student Notes Now Billable

[mehc012]

Yea, that's not what scribing was when I went through the training. In the state I was in several of the responsibilities you listed are actually illegal for scribes according the training I went through. The only things scribes were able to do were to record H&P (or progress notes), physical exam findings, and pertinent lab values that the physician stated should be included. You could not enter information about procedures or tests you were not physically present for. Idk if that's a difference with state laws, but what you're describing sounds like some of what the scribes I've worked with did with more that were not part of their duties and some that they actually were not allowed to do in the 2 states I've worked with scribes in. Granted, I did the training almost 10 years ago, so things may have changed.

Some of what you're describing sounds like just dealing with docs who suck/are jerks if they're not verbalizing some of the physical exams they're performing. Some of it sounds like on-the-job learning you should be able to pick up as you go. Some of it sounds like it's outside your responsibilities (though again, could be variances in law, I know you definitely weren't supposed to be doing anything in terms of billing though). However, it's still different (and imo easier) for a physician to look over a note that someone took while while the doc was performing the interview and exam than review a note taken based on an interview and exam they were not present for, as the doc will have to go and do everything again themselves, then review the note for which is based on an interview and exam they did not witness and try to figure out which points were relevant to that interview compared to theirs and give valid feedback and teach (which they should be doing).

Since you're comparing clinical years to scribing, I have to ask if you have any experience regarding the responsibilities and limitations of medical students during their clinical rotations? As in which parts of notes we're allowed to contribute to, the extent to which we can perform certain physical exams, and under what circumstances we can perform/assist with procedures? Honestly, it sounds like you may be disappointed with what you'll actually be able to do as a medical student given your past experiences.

I am absolutely prepared to be disappointed with clinical years in med school, just as I was really disappointed with the preclinical years and how little they expected of us. I learned more from scribing and taking interesting undergrad level courses than I've learned yet in med school, and I won't be surprised if that continues. Honestly, med school mostly seems like a waste of time.

Why would I need them to tell me the entire cardiac exam if I see them perform a cardiac exam, know what the normals are, and know it's normal because they tell me when it's not? Why would you ever not be present for the procedure? Why would your doc ever be anywhere near a patient without you by their side observing them? It's kind of silly to say we shouldn't have anything to do with billing when the entire chart is used for billing and billing requirements. Heck, we'd even put in the billing level. Doc still checks everything out.

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[Stagg737]

I am absolutely prepared to be disappointed with clinical years in med school, just as I was really disappointed with the preclinical years and how little they expected of us. I learned more from scribing and taking interesting undergrad level courses than I've learned yet in med school, and I won't be surprised if that continues. Honestly, med school mostly seems like a waste of time.

Why would I need them to tell me the entire cardiac exam if I see them perform a cardiac exam, know what the normals are, and know it's normal because they tell me when it's not? Why would you ever not be present for the procedure? Why would your doc ever be anywhere near a patient without you by their side observing them? It's kind of silly to say we shouldn't have anything to do with billing when the entire chart is used for billing and billing requirements. Heck, we'd even put in the billing level. Doc still checks everything out.

It seems like we're talking about different things in a lot of these instances, and I don't feel it's productive anymore. The only thing I'd add is that when I was doing the training, you didn't do anything having to do with billing because it was illegal in that state and also went against that hospital's policies as to what parts of the note scribes actually had access to (scribes only had access to certain sections of the note).



Anyway, I'm curious as to how many attendings would actually use medical student notes for billing purposes after this policy is enacted. Any thoughts or reservations about this?

 

[mehc012]

It seems like we're talking about different things in a lot of these instances, and I don't feel it's productive anymore. The only thing I'd add is that when I was doing the training, you didn't do anything having to do with billing because it was illegal in that state and also went against that hospital's policies as to what parts of the note scribes actually had access to (scribes only had access to certain sections of the note).



Anyway, I'm curious as to how many attendings would actually use medical student notes for billing purposes after this policy is enacted. Any thoughts or reservations about this?

Right, sure...but putting aside whether it was the common way to scribe or legalities of billing, my point is that untrained, non-med-school-educated college kids were well able to write notes like this after very little training and practice, and I see no reason why medical students should not be able to do so as well. Those docs were able to use and revise 20-30 notes per day made by the scribes, because that was all they had to do for documentation. Writing that volume of notes and looking to see what changes were made to each of them by the docs each day was an incredibly powerful way to improve at note writing. So why can't we make a similar system work for medical students?

 

[VA Hopeful Dr]

I'm saying you have to explain and document it. Whether or not it will prevent licensing, I have no idea. But it becomes one of those things that will always make your licensing application take much longer to process and lead to a great deal of extra work for you every single time you apply for a new license. In the future, should you be named in a malpractice suit again, either as a resident or attending, it will also always be brought up and warrant explanation, including in future court litigation.

I think this will be a very very rare event. First, med student notes were part of the record for quite a long time. In fact they still are in many places. Second, residents usually get dropped from lawsuits pretty early on, why would students have it worse than residents?

 

[Coltuna]

I have very little meaningful information to add to this thread but are you maybe confusing a scribe with a transcriptionist @Stagg737 ? I've worked in 3 scribe jobs with different companies and @mehc012 's description is spot on for all of those gigs. We're present for every single aspect of the physician-patient encounter during their visit unless the patient requests only the doc. This includes witnessing and documenting history, physical exam, procedures, description of lab results, follow up plan, etc. Most of the docs I work with are literally just glancing at my note to make sure a few pertinent things are in there before "signing off."

Edit: I glanced over most of this thread, so I'm probably missing the main argument here.

 

[Mass Effect]

I think this will be a very very rare event. First, med student notes were part of the record for quite a long time. In fact they still are in many places. Second, residents usually get dropped from lawsuits pretty early on, why would students have it worse than residents?

At my place, med student notes aren't part of the record so I can't speak to places that are. But if a med student is named in a suit, whether their name gets dropped or not, they will have still been named and will still have to check that box on licensing apps.

 

[dpmd]

At my place, med student notes aren't part of the record so I can't speak to places that are. But if a med student is named in a suit, whether their name gets dropped or not, they will have still been named and will still have to check that box on licensing apps.

And it will have literally no effect. Even if you don't check the box, as long as you have a good explanation you will be ok (this happened to my co-chief who did not know she had been named in a suit during residency because she was quickly dropped and the self insured hospital somehow never notified her so when credentialing for her first job it came up, not that it was without some hassle but that lack of notification should not be the norm)

 

[VA Hopeful Dr]

At my place, med student notes aren't part of the record so I can't speak to places that are. But if a med student is named in a suit, whether their name gets dropped or not, they will have still been named and will still have to check that box on licensing apps.

My med school has had student notes as part of the record since 1977. None have ever been named in a lawsuit.

Yes, you'd have to mention it but it's two lines: date of suit, result (check box that says dropped), and that's it. No license in the last 15 years (that's as far back as online records go) has been denied for that.

 

[Mass Effect]

And it will have literally no effect. Even if you don't check the box, as long as you have a good explanation you will be ok (this happened to my co-chief who did not know she had been named in a suit during residency because she was quickly dropped and the self insured hospital somehow never notified her so when credentialing for her first job it came up, not that it was without some hassle but that lack of notification should not be the norm)

Not sure I'd go with "even if you don't check the box, as long as you have a good explanation" when it comes to licensing, but that's just me.

My med school has had student notes as part of the record since 1977. None have ever been named in a lawsuit.

Yes, you'd have to mention it but it's two lines: date of suit, result (check box that says dropped), and that's it. No license in the last 15 years (that's as far back as online records go) has been denied for that.

First, I never said a license was denied for it. I spoke strictly about the hassle of it and nothing more. Second, not sure what state you're in, but in my state any time you're named in a suit, it requires much more than just a check box that says dropped. My colleague who is now a fellow and was named in a suit as a PGY 2 can attest to all the BS needed for the medical board.

 

[dpmd]

Not sure I'd go with "even if you don't check the box, as long as you have a good explanation" when it comes to licensing, but that's just me.



First, I never said a license was denied for it. I spoke strictly about the hassle of it and nothing more. Second, not sure what state you're in, but in my state any time you're named in a suit, it requires much more than just a check box that says dropped. My colleague who is now a fellow and was named in a suit as a PGY 2 can attest to all the BS needed for the medical board.

It is not like I advise purposefully leaving it off, just that in case you didn't know or forgot at some point it isn't the end of the world.

 

[BeddingfieldMD]

Title is pretty self-explanatory, but here's a link for those interested:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf

Thoughts? Critiques? Overly-dramatic opinions about the end of medicine as we know it?

Interesting. Of course, it still requires attending physician cosignature, just as is required presently with resident/fellow notes. But as others have mentioned, I think the big question will be will med students be liable and potentially named in lawsuits for misstatements in the notes? I believe currently they are protected since the notes are literally "for practice" and don't constitute an actual part of the medical record. Of course, they are sometimes copies by the residents, whose notes are then cosigned by the attendings. But that's another story.

As my memory serves me, the quality of med student notes varies dramatically, particularly as students progress from MS3 to MS4 positions. I wonder if some attendings will find it's not worth cosigning early MS3 notes because so much revision is required?