Resident admitting patient late at night

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Resident admitting patient late at night

Postby Shoshana » Mon Mar 19, 2018 7:39 pm

If a resident admits a patient late at night and does a complete history, exam and A & P. This day is not billed. The attending sees the patient the next day and personally performs an exam and Assessment & Plan while and directly refers to the patients History components, can those be counted for the attending to get a complete H & P on the day he sees the patient.
Note states: "Please see resident H & P for additional and complete history documentation. Patient is 57 year old with history of ankle dislocation and fracture that is post-surgical care. She is doing well, pain is controlled. No additional complaints. Denies fever/chills/SOB. On exam she is not in distress, alert and oriented, PERLA, Cards-rrr, no mumurs, lungs-CTA bilaterally, abd-NT, ND, Good bowel sounds, Skin- surgical dressing intact with no drainage, left leg with no edema. She has been cleared by ortho for discharge. Waiting for PT assess to ensure patient is capable of moving with walker. Medical issues are stable and has had not post-op or surgical complications She will need pain control for a few days and to be non-weight bearing until released by ortho. She will need work excuse and restrictions until cleared by ortho in 2 weeks. Anticpate discharge today after PT assessment. Patient seen and dw resident team - Dr. A, Dr. B and Dr. C.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
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Re: Resident admitting patient late at night

Postby admin » Tue Mar 27, 2018 2:08 pm

The statement from the attending has to clearly state they (personally) saw and evaluated the patient, reference the date of servie and document, and attest to the documentation for it to be counted. It is then billed for the day the attending saw the patient.

Good example: I personally saw and evaluated Mr Smith, today 3/26/18. I agree with the documentation done by Dr Resident on 3/25/17, in addition........

Insufficient: Patient was seen and evaluated, I agree with the documentation done by Dr. Resident on .....

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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Re: Resident admitting patient late at night

Postby jcm2116 » Wed Mar 28, 2018 10:58 am

What happens if there is no date noted by the admitting on when exactly he or she saw the patient? The attestation would say that he examined the patient and agree with the resident and his/her additional comments, etc. Which DOS should be reported? This is an issue I see a lot.
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