Medical Staff (MS) (Critical Access Hospitals / Critical Access Hospitals)
Q. What patient care activities, such as the History and Physical, can a medical student perform and document in the medical record?
Medical Students Doing H&P
Updated | November 24, 2008
A. A medical student has no legal status as a provider of health care services. The organization should have policies and procedures which address the activities of medical or other students and what documentation from students can be entered into the record.
With regard to whether a history and physical by a medical student can fulfill the requirements for a history and physical as required the history and physical entered into the record must be performed, documented and authenticated by a practitioner with privileges to do so, or delegated to a non-LIP when allowed by law and regulation (see the FAQ"Delegation of the History and Physical"). Since the medical student is not an LIP, the H & P by the medical student would not fulfill the requirements.
In addition, it may be acceptable, in accordance with organization policy and law and regulation, for students to perform certain patient care activities under the direct supervision of a qualified LIP who enters and countersigns appropriate documentation in the medical record, as required by organization policy, and accepts legal accountability for those activities and documentation.