Documentation
The Center for Medicare and Medicaid Services (CMS) has specific guidelines about the documentation required in the medical record from a teaching physician when an ACGME resident or fellow is involved in the care of a patient.
If the resident provides the documentation, the teaching physician is required at a minimum to personally document that he/she performed the service or was physically present during the key or critical portions of the service and that he/she was actively involved in the management of the patient. The teaching physician note needs to support the fact that he/she saw the patient, evaluated the patient and participated in the plan. When health records are reviewed, the combined documentation by the resident and teaching physician is used to support the medical necessity of the services provided.
Unacceptable Teaching Physician Documentation:
•‘Agree with above’, followed by legible counter signature or identity.
• ‘Rounded, reviewed, Agree’, followed by legible countersignature or identity
• ‘Discussed with resident, Agree’ followed by legible countersignature or identity
• ‘Seen and agree’ followed by legible countersig nature or identity
• ‘Patient seen and evaluated’ followed by countersignature or identity
• A legible countersignature or identity alone
Minimally Acceptable Documentation
• I was present with resident during the history and exam. I discussed the case with the resident and agree with findings and plan as documented in the residents note.
• I saw and evaluated the patient. I reviewed the residents note and agree, except that (personalize the note).
Remember:
• The teaching physician documentation should be personalized to the patient. A generic attestation alone is not sufficient and does not support
the medical necessity of the teaching physician involvement.
• Dictation should indicate who dictated the note
• Each person contributing to the documentation should sign the note
The only services provided by a medical student that the teaching physician can use is documentation of the review of systems and/or past family and social history.