Examples of Teaching Physician Attestations

Transcription

1 Examples of Teaching Physician Attestations Medical Student Involvement I have reviewed and confirmed the review of systems and past/family and medical history as documented by the medical student. I have reviewed and confirmed the review of systems and past/family and medical history as documented by the medical student. However it is also noted that {Provider fills in further details as appropriate}. E&M Outpatient Attestation Outpatient Visit with GC Modifier (Supervised resident-patient seen by resident and Teaching Physician) I have seen and evaluated the patient. I agree with the resident s note as documented. I have seen and evaluated the patient. I agree with the resident s note except {TP adds appropriate information}. I was present with the resident during the visit. I discussed the case with the resident and agree with the note as documented by the resident. Outpatient Visit with GE Modifier (Primary Care Exception Clinics Patient not seen by a Teaching Physician, Resident only) TP reviews care provided by resident while the patient is in the clinic and provider agrees: While the patient was in clinic or immediately following the patient leaving the clinic, I reviewed the patient s medical history, the resident s findings on physical examination, and the patient s diagnosis and treatment plan with the resident and agree with the information documented. Page 1 of 6

2 TP reviews care provided by resident while the patient is in the clinic and provider disagrees: While the patient was in clinic or immediately following the patient leaving the clinic, I reviewed the patient s medical history, the resident s findings on physical examination, and the patient s diagnosis and treatment plan with the resident and amend the {diagnosis, plan, etc.}. E&M Inpatient Attestation Admitting Note: Documentation by Resident with Teaching Physician: I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident s note. OR Documentation by Resident with Teaching Physician: I saw and evaluated the patient. I reviewed the resident s note and agree with findings and plan as documented in the resident s note. Subsequent Note: Documentation for Follow-up Inpatient Visits: I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident s note. Counseling and Coordination of Care I have spent more than 50% of this minute encounter {total number of minutes of encounter} in counseling and/or coordination of care with the patient. I discussed with the patient {attending must provide details as to what was discussed with patient during this time}. Page 2 of 6

3 OR I have spent minutes of this minute encounter in counseling and/or coordinating care. I discussed with the patient {attending must provide details as to what was discussed with patient during this time}. OB/GYN Deliveries I was present for the vaginal delivery of the infant by maternal effort and delivery of the placenta. Please see delivery note for details. I was present for the operative vaginal delivery of the infant and delivery of the placenta. Please see delivery note for details. I was present for the C-section delivery of the infant and delivery of the placenta. Please see operative note for details. I was present only for the delivery of placenta. Please see delivery note for details. I was immediately available for the delivery of the infant and placenta. (This is not billable but is an option for documentation in rare cases of attending being caught elsewhere.) Procedures Minor Procedure Attestation Procedure Only with resident: I was present for the entire procedure. Procedure and E/M with the resident: Page 3 of 6

4 I saw and examined the patient and discussed with resident, agree with the resident s note and was present for the entire procedure. Single Surgery Attestation TP is present for entire surgery: I was present for the entire surgery. TP is present for critical and key portions of surgery: I was present for the critical and key portions of the surgery and I was immediately available to provide assistance. Overlapping Surgery Attestation TP is present for the critical/key portion of two overlapping surgeries: I was present during the key and critical portions of the surgery and I or Dr. X (another attending surgeon) was immediately available during the remainder of the procedure (the non-critical portions). Endoscopy Attestation TP must be physically present from the insertion of the endoscope through the removal of the endoscope. (Viewing through a monitor in another room does not constitute physical presence.) I was present for the entire procedure from insertion of the scope until removal of scope. Remainder of page intentionally left blank. Page 4 of 6

5 Procedures performed in Treatment Room or on Unit/Floor by Resident Alone (i.e., chest tubes, arterial lines, etc.). (These are examples where Resident sees patient and Teaching Physician DOES NOT see patient. These encounters are non-billable). Resident sees patient alone. Case discussed with Resident. I reviewed the progress note and agree with the resident s findings and plans as written. Case discussed with resident. Resident sees patient and performs procedure alone (i.e. chest tubes, arterial lines, etc.). Case discussed with Resident. I discussed the case with the resident and we determined the performed procedure was medically necessary. I reviewed the progress note and procedure details and agree with the resident s findings and plans as written. Case discussed with resident. Revision History: Effective Date Revision Letter Document Author Description of Change December 2012 A Cassandra Romero Initial Release. May 2014 B Sandy Colson Revision August 2014 C Sandy Colson Inserted additional information Page 5 of 6

6 March 2016 D Sandy Colson Inserted additional information Page 6 of 6