Wiki Teaching hosp/Dr's signature???

[skm510@live.com]

OK, so this is an ongoing issue for me... It had always been my understainging that when a resident dictates an H&P for a Dr the note must state patient was seen and discussed with Dr... In my current job all the notes say is pt was dicusssed with Dr. Am I wrong? doesn't there have to be a note in the chart stating that the attending did infact "see" the patient?

 

[christina78239]

doctor notes

to my understanding, yes in the progress notes should be documentation that doctor did see and speak with the patient regarding whatever. I have also seen where the resident does the progress report without ever seeing the patient first. goes right to the chart. In the real world yes. this is wrong.