To the Editor:

The authors of “Off the Charts: Teaching Students in Compliance With HCFA Guidelines” [May 2000] are off-base with their recommendation that medical students' patient notes be kept in a separate “teaching” file.

Medical students play an active part in the patient care delivered by preceptors. They see patients, ask detailed questions, perform examinations and make observations. This role cannot be denied. In fact, students often enhance patient care by spending extra time with patients and providing more data than the preceptor could obtain alone.

Along with teaching the students, do the authors of the article suggest that the preceptor copy the students' valuable notes? If a lawsuit occurs and a medical student is involved, how are the sequestered “teaching” notes handled? Keeping students' documentation in a separate teaching file is impractical for this reality and for other logistical reasons of cataloging and space.

The Health Care Financing Administration's (HCFA) rules may make us play games to get paid for care, but let's not let HCFA contaminate medical education in the ambulatory setting. The care is entirely the preceptor's responsibility, but the record may be a team effort.

Author's response:

We fully agree with the spirit of Dr. Scherger's comments as well as his assertion that students play an important role in providing care to patients. However, while leaving students' notes on the chart is reasonable, it is also potentially dangerous if preceptors fail to do adequate documentation on their own.

According to HCFA documentation guidelines for teaching physicians and other professional organizations' interpretation of those guidelines, only the review of systems and the past, family and social histories may be drawn from students' documentation. So preceptors must document the history of present illness, physical examination and medical decision making.

HCFA guidelines truly are being allowed to “contaminate medical education.” Physicians must encourage their professional organizations to lobby HCFA to acknowledge the role that the preceptor/student team plays in caring for patients. Until then, do your own documentation.