Faculty Practice Plans Compliance Programs, Office of Compliance and Regulatory Affairs, Compliance Office 210-567-2014, ComplianceLine 1-877-507-7317 Faculty Practice Plans Compliance ProgramsCompliance Line 1-877-507-7317Compliance Office 210-567-2014Office of Regulatory Affairs and Compliance

Medical Student Documentation

April 2, 2004

  1. Medical students can obtain the following information from a patient outside the presence of a teaching physician or resident and document in the medical record:
    1. Review of Systems

    2. Past Family History

    3. Past Social History

    4. Past Medical/Surgical History
  2. Teaching Physicians may not refer to or rely on a student's documentation of physical exam findings, medical decision making, or history of present illness in their personal notes.
  3. If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.
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