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

Area of Science:

• Medical Education
• Health Informatics
• Clinical Documentation

Background:

• Centers for Medicare and Medicaid Services (CMS) policy changes permit medical student documentation in electronic health records (EHR) for billable encounters.
• Medical student documentation is a core entrustable professional activity, necessitating evaluation of its implementation and impact.

Purpose of the Study:

• To evaluate the opportunities for medical student documentation and feedback across various clerkships following new CMS policies.
• To assess the successful implementation and adoption of student documentation within a health system.

Main Methods:

• A multidisciplinary workgroup implemented a system for student documentation, including education and EHR usage tracking.
• Billing data from August 2018 to August 2019 tracked student-involved services and encounter types.
• End-of-clerkship evaluations assessed student opportunities for documentation and feedback.

Main Results:

• Over 6,900 patient encounters were billed as student-involved services, with 52% inpatient and 47% outpatient.
• Approximately 90% of students reported opportunities to document in the EHR across most clerkships.
• Over 85% of the time, documentation opportunities were accompanied by feedback, with most students perceiving a moderate to high impact on patient care.

Conclusions:

• The implementation of student documentation successfully met compliance and educational needs within the health system.
• The changes were adopted without resulting in potential abuses of student work for service.