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Documentation Guidelines Module
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“The strokes of the pen need deliberation as much as
the sword needs swiftness”
Julia Ward Howe |
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The traditional practice of having students use the
patient’s chart to record their findings is beneficial in two ways: (i) It
allows the preceptor to evaluate the student’s documentation skills, and (ii)
It reduces the amount of time a preceptor spends on paperwork. However, the
Health Care Financing Administration (HCFA) maintains that documentation by
anyone other than the physician is insufficient evidence that the physician
actually provide the services for which the patient was billed. In short, physicians
must personally document all key aspects of a patient’s visit regardless of
whether a student has already recorded the same information. Although the
HCFA regulations apply only to Medicare and Medicaid patients they may apply
to other insurance carriers in the event of a government review of practice
records. So what approach should be taken in regard to student documentation?
The following are some suggestions: 2. Physician
Role - Personally document every patient encounter just as you would in
the absence of a student. 3. Student
Role - Have your student record the patient information in a small
notebook or on the SOAP forms provided HERE. This practice is beneficial in
2 ways: (i) It allows you to review the student’s documentation skills, and
(ii) Because all the student’s SOAP notes are compiled in one source (instead
of dispersed within individual charts) you can determine to what degree their
documentation skills have improved throughout the month. |
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to Ritch Florek, Last Modified: |
