Resident Supervision Guideline
Guidelines for Working with Residents
As medicine has changed, many of the rules around documentation have become more complex. The world of medical education is no exception. Many of us recall that the attending physician would write a cryptic “agree with the above” and co-sign the resident’s note to document their involvement in patient care. Such minimal documentation is no longer acceptable. However, neither is it necessary or desirable for the attending to completely reproduce the resident’s note. What follows is a description of the rationale for and levels of documentation required in different settings teaching residents (much more rigorous requirements apply to teaching medical students).
There are four major rule-makers that control supervision and documentation with respect to residents: 1) the State Licensing Board; 2) the institution where the resident practices; 3) the training program’s requirements; 4) Medicare. Each of these imposes different requirements on the attending physician’s documentation.
The State Licensing Board
Residents are licensed to practice within the approved curriculum of the training program. As long as the resident is on an approved rotation, there are no specific documentation requirements.
At YKHC we like ALL of our notes to be co-signed by an attending physician so that we can go back to someone that works here if a result comes back 6 weeks down the road or other situation. For ER patients and inpatients, when you cosign a note, you can add some of your own rationale or other physical findings if you like. For Medicare patients, see below, as it is more strict. For clinic patients, sometimes a co-signature is all you need, but often you may still benefit from adding a small amount of your own voice to the notes if you would like something mentioned in addition to what the resident wrote.
Medicare requirements are the most onerous. Medicare cannot be billed for services provided solely by a resident. Outside the resident's home base Family Practice Center, the attending physician must personally see and examine the patient if Medicare is to be billed. This rule applies to all settings, including inpatient and outpatient.
Medicare does recognize the value of work performed by the resident in gathering the history, examining the patient and documenting findings. However, they require that the attending personally perform the key history, key exam and key decision-making. The attending’s documentation must establish that the attending did these three key elements.
The attending is free to determine the key element in each case. Usually this will be the disease that causes the chief complaint or reason for the visit.
The attending’s documentation requirement is different depending on whether he/she saw the patient with the resident or separately. The most common scenario, especially in inpatient settings, is for the attending to see the patient separately from the resident. In that case, other than documenting his or her performance of the key elements, the attending can refer to the resident’s note for all other documentation, such as PMH, social history, family history, meds, ROS, allergies and exam of organ systems other than the key ones. The level of service billed is determined by the combined documentation done by the resident and attending.
For example, in admitting a diabetic patient with pneumonia, after reviewing the case with the resident, the attending could see the patient, gather the HPI, review the vital signs, examine the chest and discuss the plan with the resident. His/her note would read:
Key History: 48 yr old diabetic with 3d hx cough, fever, sputum production and SOB.
Key Exam: T 101.2, mild respiratory distress O2 SAT 88%, rales at RLL, CXR with RLL infiltration.
Key Decision-making: Community acquired pneumonia with hypoxemia. Admit to medical ward for oxygen and antibiotics.
See resident’s note for complete H&P details. Agree with findings and plan per resident.
Medicare accepts a lesser level of documentation if the attending sees the patient with the resident. In that case, it is sufficient to document the attending’s presence and agreement with the resident’s note:
Seen with Dr. _______________ . Agree with his/her findings and plan as documented.
When submitting a bill to Medicare for services provided in conjunction with a resident (a “teaching encounter”), the attending must attach a modifier “GC” to the CPT code. “GC” indicates to Medicare that a resident was involved and documentation by the resident may be included in the attending’s documentation. Do not use “GC” with any other third-party payer. The charge and payment when a resident is involved is no different.