Out with the Old,in with the New
Published on Sat Feb 01, 2003
The new template you can expect from teaching physician documentation, mentioned in the article on page 3, differs significantly from the two templates provided by the Association of Medical Colleges that comply with Medicare's old rules for teaching physicians.
The following templates are no longer necessary, CMS seems to be suggesting: Template A (old guidelines): "History as documented above by Dr. Resident reviews with patient and resident. It is noted (you may add anything else remarkable to history, PFSH, ROS)_______. My exam confirms (revises), or I find upon exam that ___________. Lab test (specify other diagnostic tests performed) results show ______________ indicating a _____________. I confirm (revise) the resident's assessment as _________ and diagnosis of ____________ and agree with the resident's plan of care as follows:___________. See resident's notes for details." Template B (old guidelines): "Resident's history review, patient interviewed and examined. Briefly, history is as follows: _____________. On exam, I find (list what you did and your findings) ________________________. Of note is:_________________. Assessment and plan reviewed with resident. Lab/tests show ________________ and I confirm/revise the differential diagnosis is _______________. Care plan reviewed. Will _____________. See resident's notes for details."
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