Documentation Issues Facing Supervising Resident Physicians

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A countersignature by itself is insufficient for both documentation and billing purposes.

Acceptable documentation
According to CMS, at minimum, the following documentation must be included when billing for services provided by the intern/resident/fellow with a teaching physician:

  • “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
  • “I was present with the 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.”
  • “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

Unacceptable documentation
Unacceptable documentation by a teaching physician includes the following examples with a countersignature:

  • “I saw and evaluated the patient”
  • “I reviewed the resident’s note and agree with the plan”
  • “Agree with the above……”
  • “Patient seen and evaluated…….”
  • “Discussed with resident and agree with plan……….”

Download the complete tip, Documentation Issues Facing Providers Supervising Resident Physicians.