Hello - If someone could clear up for me what or if there are any documentation requirements for a doctor to submit on an operative note when teaching with a resident. I know there is a teaching attestation that is needed on e/m entries. Is there something needed on a op note? thanks so much for your help in advance
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Wiki documentation requirements for a teaching hospital
- Thread starter cjpaddy
- Start date
cpc2007
Guru
Hi,
Yes there is an attestation required for operative reports as well when a resident dictates the operative report. There are three different attestations based on the type of surgery performed:
1) For a minor procedure (defined as one typically taking less than 5 minutes such as a simple suture), the teaching physician must dictate "I was present for the entire procedure."
2) For a major procedure, the teaching physician may dictate either "I was present for the entire procedure" or "I was present for the key/critical portions of the procedure and available to assist for the entire procedure." The requirement is that the teaching physician was present for the key/critical portions and available to assist throughout the entire procedure, but if they were present for the entire procedure that would exceed the requirement.
3) For endoscopies, the teaching physician may dictate either "I was present for the entire procedure" or "I was present for the entire viewing of the endoscopy." The requirement is that the teaching physician was present during the entire viewing but of course if they were there for the entire procedure, that statement would also suffice.
I hope that helps
Have a good day
Kim
www.codingmastery.com
Yes there is an attestation required for operative reports as well when a resident dictates the operative report. There are three different attestations based on the type of surgery performed:
1) For a minor procedure (defined as one typically taking less than 5 minutes such as a simple suture), the teaching physician must dictate "I was present for the entire procedure."
2) For a major procedure, the teaching physician may dictate either "I was present for the entire procedure" or "I was present for the key/critical portions of the procedure and available to assist for the entire procedure." The requirement is that the teaching physician was present for the key/critical portions and available to assist throughout the entire procedure, but if they were present for the entire procedure that would exceed the requirement.
3) For endoscopies, the teaching physician may dictate either "I was present for the entire procedure" or "I was present for the entire viewing of the endoscopy." The requirement is that the teaching physician was present during the entire viewing but of course if they were there for the entire procedure, that statement would also suffice.
I hope that helps
Have a good day
Kim
www.codingmastery.com