deyoung
Guru
I am new to E/M and trying to understand how to have our residents and teaching physicians (TP) correctly document an inpatient consult.
This is my understanding of what's required...please provide feedback:
1. Total time of visit (entered by resident).
2. Reference that visit was >50% counseling and/or coordination of care (checked off by resident).
3. TP performed the service or was physically present during the key or critical portions (this has to be documented by TP & not resident).
4. Participation of TP in management of patient (documented by TP, not resident).
5. Time TP was actually physically present (I know they can only bill for their time, but not sure if this is required in note...but then how would I know their time?).
6. Description of counseling/coord. of care topics. (Do both the residents note and TPs note have to have this?)
7. Request for consult (is this required in the consultants note in a shared record? or is it just okay that the referring Dr documented the request? Is it my responsibility as the consultant to make sure the ref Dr documented the request?)
8. Reason for consult
9. Report from consultant in shared record.
Whew! Sorry so long! Thanks so much for the feedback!
This is my understanding of what's required...please provide feedback:
1. Total time of visit (entered by resident).
2. Reference that visit was >50% counseling and/or coordination of care (checked off by resident).
3. TP performed the service or was physically present during the key or critical portions (this has to be documented by TP & not resident).
4. Participation of TP in management of patient (documented by TP, not resident).
5. Time TP was actually physically present (I know they can only bill for their time, but not sure if this is required in note...but then how would I know their time?).
6. Description of counseling/coord. of care topics. (Do both the residents note and TPs note have to have this?)
7. Request for consult (is this required in the consultants note in a shared record? or is it just okay that the referring Dr documented the request? Is it my responsibility as the consultant to make sure the ref Dr documented the request?)
8. Reason for consult
9. Report from consultant in shared record.
Whew! Sorry so long! Thanks so much for the feedback!