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



When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships.


In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2018 to August 2019, locations and types of student-involved services (student-faculty or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed before August 2018, it was not possible to compare with prior student experiences.


In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents, and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (> 90%) viewed their documentation as having a moderate or high impact on patient care.


Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service.





Published Version (Please cite this version)


Publication Info

Gagliardi, Jane P, Brian Bonanno, Eugenia R McPeek Hinz, R Clayton Musser, Nancy W Knudsen, Michael Palko, Felice McNair, Hui-Jie Lee, et al. (2021). Implementation of Changes to Medical Student Documentation at Duke University Health System: Balancing Education With Service. Academic medicine : journal of the Association of American Medical Colleges, 96(6). pp. 900–905. 10.1097/acm.0000000000003729 Retrieved from

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Jane Patricia Gagliardi

Professor of Psychiatry and Behavioral Sciences

Jane P. Gagliardi, MD, MHS, FACP, DFAPA completed medical school, residency training in combined internal medicine-psychiatry, and her masters of health science in the clinical research training program at Duke, where she has remained on faculty since completing residency training. Dr. Gagliardi has been involved in the educational programs in the Department of Medicine, where she served as Clerkship Director and Director of Undergraduate Medical Education for nearly a decade through June, 2014 and in the Department of Psychiatry and Behavioral Sciences, where she served as the Associate Program Director for the Psychiatry Residency Training Program from 2011 till 2013, Director of the Psychiatry Residency Training Program from 2013 through 2019, and Director of the Medicine-Psychiatry Residency Training Program starting in 2019. She served as Vice Chair for Education in Psychiatry from 2014 though 2021. She is a small group leader in the medical school Clinical Skills course and founded and co-directs the medical school Evidence-Based Medicine course. Dr. Gagliardi is particularly interested in the interplay between patient safety measures, various pressures in medicine including implementation of the electronic health record, and medical education, and equity, and she has worked to develop and encourage projects in patient safety and quality improvement. She does inpatient clinical work in both departments, spending time on the General Medicine, inpatient Psychiatry, combined Medicine-Psychiatry, Consultation-Liaison Psychiatry, and Emergency Psychiatry services.

McPeek Hinz

Eugenia Renee McPeek Hinz

Assistant Professor of Medicine

As a physician informatician, my career  has spanned from clinical practice to research focusing in on improving the quality and safety of care through the Electronic Health Record (EHR).  My journey began as a Med/Ped Resident and then nearly 10 years as primary care physician at the Cleveland Clinic.  


Robert Clayton Musser

Assistant Professor of Medicine

Clinical & medical informatics, particularly the design, implementation, and evaluation of systems such as Clinical Decision Support (CDS), Computerized Physician/Provider Order Entry (CPOE), and other aspects of the Electronic Health Record (EHR)


Nancy Wolters Knudsen

Professor of Anesthesiology

Healthcare costs in the United States are at an all time high. In 1997, 13.5% of the Gross Domestic Product was spent on healthcare. Ten percent or 1.3% was spent in the intensive care unit (ICU). Over 500,000 patients/year die in an ICU setting. ICU mortality rates average 10-20%. Intensivists are now widely recognized as one of the keys to improving outcome in the length of stay and cost/case. My research interests lie in utilizing our scarce resources for the most appropriate patients, those who will derive the most benefit from ICU care. Through analyzing the transfers to our ICU, we have found that those patients on a ventilator and with renal failure have a higher mortality than other patients. Scoring systems have been routinely used as well, but can be difficult to apply in the small hospital setting. We have also documented that over half of the trauma and floor emergencies appear at night when most institutions do not have attendings available. The Duke ICU has had in-house attending coverage since 1998 and has a mortality rate of 4% for the year 2001. It is not enough to just improve care, but to improve the experience for the family during this very stressful time. We have shown that the presence of intensivists 24/7 has improved family communication and satisfaction as well. My goals are to continue to improve outcomes for patients and their families by streamlining care yet keeping an eye on the individual patient and their family's emotional needs.
I am also interested in mechanical ventilation and ways to improve morbidity/mortality in this group of patients. I am a member of the Duke ARDSnet and Duke ARDSnet2 research teams.


Alison Suzanne Clay

Adjunct Associate Professor of the Practice of Medical Education

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