Trauma

jhlitt

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My question is if I have a residents documentation plan and my trauma doctor signs beside it, does my trauma doctor have to have it word by word of what they agree with from the residents plan discription?
 
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Teaching physician guidelines

If you are talking about a patient covered by Medicare, Medicaid or other government payer, then a simply signature is NOT sufficient to allow for billing under the teaching/attending physician.

The teaching physician must attest to his/her actual presence at the bedside and participation in the history, exam and medical decision making. The TP should also note any differences in his/her observations from those recorded by the resident. The TP should then indicate agreement with the resident's documentation and sign/date.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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