Wiki Teaching Physician Documentation

[geugene]

Is it considered enough documentation to link the residents note when the teaching physician dictates the following statement?

"pt. seen and examined. Agree with above. Proceed with chemotherapy. Signature ." or "Agree with above plan. Pt has diarrhea, not eating. signature ."

It's my thoughts that more is need to id the link to resident's note.

Thanks in advance for your comments.

Glynis

 

[FTessaBartels]

Carrier differences

Some of the preferences for wording the attestation statement are carrier-specific. Basically ... the teaching physician must indicate his/her own face-to-face contact with patient, his participation in the history, exam and MDM, and his concurrence with the documentation as recorded by the resident. And, of course, must sign the report (no stamps allowed).

Eg: Patient seen and examined. I participated in the history, exam and medical decision making for this encounter, and agree with the resident's documentation above. /s/signature

Bear in mind, there are a lot of ways to state this. Sometimes the Teaching Physician does NOT agree with everything the resident documented. (Eg: "On my exam, the abdomen was tender and there was guarding.")

Check with your compliance office for further guidance.

F Tessa Bartels, CPC, CEMC