Wiki Linking Statement Opinions Needed

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renifejn

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I have a couple situations with teaching physicians and linking statements and I would GREATLY appreciate a few opinions on whether or not they are sufficient.

Ex 1 Fellow documents consultation. Teaching physician documents "I saw the patient with Dr. Y and I agree with his findings and suggestions." The TP then writes the patients problems and then "suggest as noted above and relists tests that fellow recommended. Will Follow"
Would you count this as an acceptable linking statement bc he did not state he examinied the pt?


Ex.2 Resident writes great H&P. Fellow writes his own H&P but wouldnt even make 99221. TP writes, "I have examined the patient early this day and agree with fellow's A&P as they were discussed with me this morning on rounds. Please see resident H&P for further details."
Would you accept see resident H&P for further details even though he doesnt write the required linking statement to the resident note?

Thanks so much in advance for your help!
 
TP attestation

This is an opportunity for education of the teaching physician as to what constitutes an acceptable attestation statement.

If you are in a teaching hospital and dealing with teaching physicians, you should have a Compliance Deptartment to help you. I'd ask for their guidance on these cases, and in general for educating the physicians on documentation.

1) I'd accept this because he did state that he saw the patient with the resident. BUT a better attestation statement would have been "Patient seen and examined with resident; I participated in the history and medical decision making and agree with the documentation as stated in resident note."

2) Again, I'd accept this because a) he is accepting the fellow's A&P (MDM), b) he's stating he examined the patient himself, c) he refers to resident note for further details. BUT a better statement would have been: "I examined the patient this morning, reviewed the history (see resident note), and discussed the A&P with fellow. I concur with the A&P as written by Fellow MD, and the H&P as documented by Resident MD."

We educate and educate and educate our physicians on the acceptable attestation statement(s). We drum it into their heads until they can rattle it off easily, and write it accurately on handwritten notes.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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