College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP

ELECTRONIC SIGNATURES DO NOT RELIEVE
TEACHING PHYSICIAN DOCUMENTATION REQUIREMENTS
- PART TWO

This Compliance Tip is a follow-up and expansion of the August 2002 compliance Tip concerning electronic signatures  & teaching physician documentation requirements when using the electronic signature system. 

The August Tip can be found on the Compliance website at http://www.med.ufl.edu/complian/Q&a/electsigs_pt1.html

As the previous tip stated, in the services involving a resident, the electronic signature system does not relieve the Teaching Physician of writing or dictating a patient specific note describing his or her involvement  in the services, carefully including all elements required by the Medicare. The teaching physician documentation must be included in the patient"s medical record.

Following are the options, under the ESA system for teaching physician documentation where a resident is involved in an Evaluation and Management service (again, regardless of the option, the teaching physician documentation must be included in the medical record and be in substantially the format outlined in the August 2002 tip noted above. ):

1.    The Teaching Physician can handwrite and sign his/her teaching physician documentation. This note must refer to the  to the resident"s service/note and the Resident"s and Physician"s note, taken as a whole, support the level of service.

2.    The Teaching Physician can dictate his/her teaching physician documentation.  The dictation must refer to the resident"s service/note, and the Resident"s dictation and the separate Teaching Physician"s dictation, taken as a whole, support the level of service.

3.    The Teaching Physician can handwrite and sign or dictate his or her own note that documents and supports the  service in its entirety. Under this option, the Teaching physician"s note need not "link" to the resident"s service/note if the teaching physician"s note can  stand alone to support the level of service billed.

4.    The teaching physician can dictate his her own note based on time, when all of the requirements for time-based billing are met. Billing based on time does not "link" to the resident"s note.

*Note - For those departments that intend all medical record documentation to be electronically available under the ESA system, dictation of  the teaching physician documentation, dictation of a separate note in its entirety, or dictation of time-based documentation, at the time the service is rendered, are the most practical options. The handwritten options are less practical because of the difficulty in getting the handwritten documentation into the patient"s electronic medical record.

It is not permissible to be ambiguous about the authorship of the teaching physician documentation. The authorship of each note or part of a note must be clear and unambiguous.  It is not permissible for the resident to dictate the entire note, including the teaching physician attestation, which the teaching physician signs.

Neither is it acceptable for the Teaching Physician to type in the Teaching Physician statement, when later reviewing the Resident"s note.   The Teaching Physician must dictate or write his/her own Teaching physician documentation at the time the service is rendered.

If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.

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