Wiki Teaching Physician Documentation

[steincamp]

I would like to know if anyone has any guidelines or advice on how to handle TP documentation when the resident dictates the note after the visit and the TP handwrites their attestation statement and signs the paper note. Both the paper clinic note and the dictated note are part of the medical record. My question is, how can the TP agree with the resident's documentation and plan of care when that record doesn't exist at the time the TP statement is written? My personal opinion is, if the TP does not want to dictate their portion of the note and continues to handwrite on the paper document; they should countersign the dictation to support that they have seen the resident's documentation and are in agreement with it. I know that countersignatures are not acceptable to support TP presence, however, I think that they should read/co-sign the dictated note to support their handwritten statement that they agree with the resident's plan of care......

Any thoughts on this?

 

[cpccoder2008]

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/downloads/gdelinesteachgresfctsht.pdf
Hope this helps.

 

[FTessaBartels]

Dictation system issue

Our dictation system ONLY allows the teaching physician to sign. Residents can dictate, but they must specify who the supervising teaching physician is. The TP reviews / edits / signs and dates the documentation. The TP must also add the attestation statement before signing. If the attestation statement is missing we do not bill it.

Hope that helps.

F Tessa Bartels, CPC, CEMC