If your attending intends on using your note for billing purposes, then please follow these steps to ensure that your note will be compliant:

1. Before the encounter, confirm with your attending that he/she plans on utilizing your eStar note for billing – as opposed to educational – purposes.
   1. The attending may want to warn the patient, as this entire process requires a foreign workflow that might catch established patients by surprise.
   2. The attending may decide to write his/her own note and attest your note as “educational” (please see two different attestations at the end of this document).
2. Ensure that you are in the correct eStar context.
3. Once the patient arrives, double click on the patient’s name to begin charting within the office visit.
   1. Prior to arrival, read up on the patient in Chart Review mode, as there is always a risk that the patient does not show.
4. Click on the “Notes” tab to begin prepping your progress note.
   1. There should be a “Medical Student Progress Note” template that auto-populates.
   2. If you have already taken the time to create your own outpatient progress note that pulls in various types of information, then feel free to use your dot phrase(s)
      to incorporate your tailored note components within this standardized template.
      1. Watch out for duplicated sections.
5. When you are ready, go see the patient on your own to perform all necessary history and physical exam components. Make sure to include the patient’s reason
   for visit in the patient’s own words stating why they are being seen.
   1. Update the “Intake” tab as you go:
      1. Allergies
      2. Med Rec
      3. Problem List (feel free to update the “Overview” sections)
      4. History – medical, surgical, family, and social (manually enter any extra social info into the “Social Documentation” box)
6. Leave the patient room, take a few moments to gather your thoughts, and then let your attending know that you’re ready to present.
   1. Feel free to pend any orders (labs, imaging, referrals, vaccinations, etc.) if you feel comfortable doing so.
7. You and the attending will then enter the patient room together so that you can present the pertinent history and physical findings to the attending in front of the patient.
   1. Your attending may need a friendly reminder about this particular step!!
8. Of course, the attending will obtain any additional history that he/she feels is necessary and then he/she must perform their own physical exam.
9. If you feel comfortable doing so, provide the patient and attending with your assessment and plan. The attending will round out your plan and wrap up the visit per usual.
10. Go back to your workstation and complete your note.
    1. Make sure to document comprehensively including HPI, ROS, physical exam findings, detailed A/P by problem, and return to clinic timeline.
       1. If your note pulls in the A/P from the problem list, then make sure you have associated all the appropriate problems with this office visit.
11. Enter your attending as the cosigner.
    1. I always save this step for last, so I never accidentally submit my note before I have completed it.
12. Your note is automatically set to “Sign at Close Encounter,” but when you have finished your note, change this setting in the bottom left to “Sign on Saving Note.”
    1. Once you’ve changed this setting, then hitting the “Accept” button will sign your note and send it to the attending for cosign.
13. Ideally, you should NOT be able to accidentally sign the office visit (closing the encounter) because med students are unable to set the E/M code (read-only).
    1. If you accidentally hit the “Sign Visit” button in the bottom right AND the attending has already entered the E/M code, then you will be given the opportunity to close the encounter prematurely…but you will be prompted to enter a cosigner again – please don’t do this and just click out instead.
14. Remind your attending to select the appropriate attestation from the drop-down menu:

    FOR ENCOUNTER BILLING PURPOSES
    I performed this service on ____. I attest that I was physically present with the medical student and the patient as the student reported the patient’s history and physical examination findings represented in the attached medical student documentation. I have verified the history and personally performed my own physical examination of the patient. I personally determined the medical decision making and billing codes for this visit. I have reviewed the attached medical student note and agree with the content and plan as written unless otherwise documented.

     

    FOR EDUCATIONAL PURPOSES ONLY
    I have reviewed the attached medical student note for educational purposes only. Please see other encounter documentation for billing and clinical decision-making purposes.