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  1. #1
    Stanmack is offline Newbie 511 points
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    Can a student write a note on a patient he did not see?

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    The outpatient component of my surgery elective is at the attending's private clinic outside the hospital. Often I am told by the nurse to write notes on patients that I have not seen, but the attending saw by himself. Basically, I have to transcribe the attending's handwritten notes of the patient encounter into the EHR. I have my own login to the EHR. I hate doing it and learn nothing from it; I didn't sign up for this rotation to be a scribe. It takes forever to do because the attending's handwriting is horrible. Is this legal, considering I had zero interaction with the patient? I looked up the AMA guidelines and its not really clear; students are allowed to write the H&P portion of the note on patients they have interviewed, the Assessment and Plan is supposed to be written by the resident or attending. Is it legal for a medical student to be essentially a scribe?


  2. #2
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    medic300107 is offline Supermedic Moderator 10494 points
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    Quote Originally Posted by Stanmack View Post
    The outpatient component of my surgery elective is at the attending's private clinic outside the hospital. Often I am told by the nurse to write notes on patients that I have not seen, but the attending saw by himself. Basically, I have to transcribe the attending's handwritten notes of the patient encounter into the EHR. I have my own login to the EHR. I hate doing it and learn nothing from it; I didn't sign up for this rotation to be a scribe. It takes forever to do because the attending's handwriting is horrible. Is this legal, considering I had zero interaction with the patient? I looked up the AMA guidelines and its not really clear; students are allowed to write the H&P portion of the note on patients they have interviewed, the Assessment and Plan is supposed to be written by the resident or attending. Is it legal for a medical student to be essentially a scribe?

    If you are in the room during the encounter yes you can write the note. If you are not in the room legally this is fraud. I would let Ross know.
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  3. #3
    don1 is offline Senior Member 544 points
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    I agree. perhaps let the attending know first is possible and find if there is a way you can be present during the clinical encounter for the notes you are asked to write. Another way is to document in the note that you did not see the patient but name the physician who say the patient. Imagine a legal case where you notes come up as evidence of your actions and what happened.

    Quote Originally Posted by medic300107 View Post
    If you are in the room during the encounter yes you can write the note. If you are not in the room legally this is fraud. I would let Ross know.

  4. #4
    Anastomosis is offline Member 510 points
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    This is obviously scutwork. But I do not believe what you are doing is illegal. If all you are doing is transcribing what the attending wrote, and not adding any of your own thoughts into it, you are essentially doing secretary work. Not technically illegal, but minimal if any learning opportunity.

    I believe it has been a while already, that medical student notes can't count for official EMR nationwide. But it looks like what you are doing is not even medical student work, it is just being a transcriber, and then the attending signs it. Once again, technically not illegal, but not something a medical student should be doing.

  5. #5
    medic300107's Avatar
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    Quote Originally Posted by Anastomosis View Post
    This is obviously scutwork. But I do not believe what you are doing is illegal. If all you are doing is transcribing what the attending wrote, and not adding any of your own thoughts into it, you are essentially doing secretary work. Not technically illegal, but minimal if any learning opportunity.

    I believe it has been a while already, that medical student notes can't count for official EMR nationwide. But it looks like what you are doing is not even medical student work, it is just being a transcriber, and then the attending signs it. Once again, technically not illegal, but not something a medical student should be doing.
    Well honestly for CMS billing a student note can't be cosigned by the attending anyway. To bill it has to be a resident or attending only note. Most places still do MS notes and have co sign but shouldn't be billing. It's fraud.

    https://www.cms.gov/Outreach-and-Edu...-ICN909160.pdf
    Last edited by medic300107; 01-11-2018 at 05:23 PM.
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    Anastomosis is offline Member 510 points
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    Quote Originally Posted by medic300107 View Post
    Well honestly for CMS billing a student note can't be cosigned by the attending anyway. To bill it has to be a resident or attending only note. Most places still do MS notes and have co sign but shouldn't be billing. It's fraud.

    https://www.cms.gov/Outreach-and-Edu...-ICN909160.pdf
    I understand what you are saying. You cannot use a medical student note, and cosign it and have it billed. I understand that. But I believe the original poster's issue is different. The attending is asking him to transcribe his hand written notes onto a computer, in essence the medical student is not functioning as a medical student, but a scribe, and then once he transcribes it, the attending signs it as his own notes. That I do not believe is illegal, as the the medical student is not inputting anything additional or what he thinks onto the note, but simply transcribing word for word what is written.

    It is similar to the transcribing service we have at my hospital, I call it in, and then somebody listens to what I say and transcribes it into a note, and I receive it later on the day and review it and sign it as my own. That transcriber is hired just as a transcriber, and probably have minimal health background.

  7. #7
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    gfliptastic is offline Member 654 points
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    Wow, how *** backward is that?! The reverse, I know is common, but I've never heard of this! In the worst hypothetical setting, it's possible for an attending to sit in a room, be on his/her phone while the MS does all the work, then write/type-in "Reviewed and agree w/ above" and that's more on vaguely legal side than this.

    I don't think you need to try to bury them, but at the same time, it will probably be beneficial to tell Ross about this so they can address it, from an educational, and pseudo-legal standpoint. It's not learning, not useful, and essentially they are getting paid (to accept you as a student) to have you scribe. Which is not cheap either.
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