So let me get this straight, the resident see's the patient then the teaching physician see's the patient but they both do not dicate till the next day ?? I recently attended the AAPC webinar E/M auditing and that stated the physician must sign with 48-72 hours. I know some doc's who short hand a H&P then later dictate it. Sounds to me like your doctor is just writing his statement seperate from the resident before he actually read it. My doctor's always write their statement on the resident's notes. What the resident could do, if in fact they are seeing the patient together, write in his dictate report that he saw the patient along with Dr. __ , that alone does not justify presence but it would somewhat show involvement for when the doctor does his own dication, then he can say " I saw patient along with resident and agree with finding and plan of care as stated his H&P, please refer back to Dr Residents notes for findings " Not sure if this is what's happening or not but here are two links for documentation for residents http://www.lamedicare.com/provider/medguide/main.asp http://www.cms.hhs.gov/MLNProducts/d...gresfctsht.pdf
Hope this helps.
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