Attending and Resident's notes

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Attending and Resident's notes

Postby Shoshana » Thu Feb 01, 2018 5:27 pm

If an attending chooses to write his own note, but attests on the resident's note from the night before "This case was discussed with the resident physicians. I have reviewed the record and agree with the above note and plan of care as was discussed. I have authorized the order for admission to an in-patient status.", can I use the information on the resident's documentation for ROS and PFSH. The physician's separate note does not refer to any of the resident's documentation.
In this example, the resident saw and admitted the patient on 1/28/2018 @ 20:28. The attending rounded, attested on the resident's note and wrote his own note on 1/29/2018 @ 16:32.
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Re: Attending and Resident's notes

Postby admin » Wed Feb 07, 2018 1:02 pm

Maybe I have misread this, but the example appears to be a violation of the guidelines with respect to teaching physicians. The whole point of the attestation is to show that the attending MD saw the patient face-to-face with the resident, and performed some or all of the service with the resident, thus allowing the service to be billed under the attending.

The attending can’t attest to visits that occurred the night before that he/she was not present at. I am assuming the attending wasn’t there, because the statement given below doesn’t mention personally having seen the patient. If they were there, then I would say the statement is non-compliant because it lacks a phrase such as “I personally saw and examined the patient.”

As far as using (it would actually constitute copying and pasting) the ROS and PFSH from a resident’s note from an encounter he/she was not present at, that is clearly not acceptable. The attending note for his/her service should stand on its own. The ROS in particular is, is by definition, a review of systems at the time of a given visit, it cannot be abstracted from a prior visit during which any given organ system might have been in crisis but is now stable (or vice versa).

Your question has been responded to by Grant Huang, CPC, CPMA
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