Electronic Health Record Documentation by Medical Students

The information presented on this page has been developed by our member organizations to help medical schools with regard to medical student documentation in the electronic health records.

Compliance

• Maximizing Medical Student Documentation in an Era of New CMS Medical Student Documentation Rules
• University of Chicago CCRC Student Documentation Guidelines 2018
• University of North Carolina Medical Student Participation & Documentation Compliance

Attestation Statements

• UNC Attestation Statement

Educational Policies

• Sisters of Charity Leavenworth Process Maps for Integrating Student Note Writing
• University of Chicago Medicine Clerkship Medical Student Note Writing
• University of Wisconsin Health Medical Student Documentation Guidelines

Faculty Development on CMS Rules

• UNC Documenting in the EHR as a Medical Student
• University of Chicago Evaluation and Management Service Documentation Provided By Medical Students

Resident Development on CMS Rules

• University of Chicago Medicine Clerkship Note-Writing Policies for IM Residency Program

References

• AAIM CME Documentation Resources
• AAIM Plenary Presentation on CMS Medical Student Guidelines
• CMS Manual System: E/M Service Documentation Provided by Students
• Compliance Issues for which CAFM, AAMC and AAPA are seeking confirmation
  regarding the new E/M Service Documentation Provided by Students