Menu

Blog Posts

interns

Documentation Tips: Teaching Interns and Residents

Posted on Mon, Mar 27, 2017
Documentation Tips: Teaching Interns and Residents

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

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 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 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 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...”

Resources:
Brundage.png

Timothy Brundage, MD, CCDS, is a hospitalist at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

Share