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Clinical documentation is an essential skill for practicing physicians, yet many medical students are not prepared for documentation required during residency.1,2 CMS rule changes now allow medical students’ notes to be used for billing.3 Residents are often the primary authors of notes and provide medical student supervision and instruction. However, little is known about how the use of medical student notes in patient documentation would impact residents. We utilized Constructivist Learning Theory to frame our work, where students construct their knowledge as residents and subsequently faculty facilitate the process.4


To evaluate how utilizing clerkship medical student notes for billing in the inpatient setting impacts resident learners.


Pediatric clerkship students were randomly assigned to one of two inpatient hospitalist teams: Control group students wrote daily notes that were not addended or used for billing purposes; and Study group students wrote notes that were used for billing. After study group students signed the notes, they were addended and cosigned by a resident and a faculty member who submitted the note for billing. There was no structured feedback or documentation curriculum provided to either study arm. We utilized a sequential mixed methods approach (quant + QUAL); junior and senior residents were given a survey with Likert-type items related to their satisfaction with the process, and an opportunity to participate in focus groups. Sixteen residents who supervised the control group and twenty residents who supervised the study group completed the survey, with responses analyzed using Wilcoxon Rank Sums tests. Focus groups were analyzed using inductive thematic analysis, with consensus among three researchers and respondent validation of participants.


In surveys, residents supervising both groups reported similar satisfaction scores with medical student documentation. There was a trend towards increased time spent providing feedback on notes among the study group, but this did not reach statistical significance. In focus groups, emergent themes included the educational value for students and residents, positive impacts on student experience, minimal negative impacts on patient care, and possible impacts on team workflow.


Medical students' notes are being increasingly used for EMR/billing; therefore, it is important to understand upstream effects on other learners. Recently published qualitative research has explored the resident perspective, but did not use a control group, and had varying results from our own with regard to workflow.5 If use of student notes for billing is to become common practice, more study is needed to understand the impacts on resident learners.

1. Englander R, et al(2016) Toward defining the foundation of the MD degree: Core entrustable professional activities for entering residency. Academic Medicine. 91(10):1352-1358.

2. Power D, Byerley J, Steiner B. (2018) Policy change from the centers for Medicare and Medicaid Services provides an opportunity to improve medical student education and recruit community preceptors. Academic Medicine,

3. Department of Health & Human Services. CMS Manual System Publication100-04 Medicare claims processing:

4. Bruner, J.S. (1961). The act of discovery. Harvard Educational Review, 31: 21-32.

5. Safdar K, Dombrosky EM, Kimberly C, et al. The One Note System: Implementation and Initial Perceptions of Student Documentation in the Electronic Health Records Under the New Centers for Medicare and Medicaid Services Guidelines. Cureus. 2020;12(8):e9702. Published 2020 Aug 12. doi:10.7759/cureus.9702

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Medical Education

To addend or not to addend? Exploring pediatric residents' perceptions of using medical students’ notes for documentation, a mixed methods approach