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

ELECTRONIC SIGNATURES DO NOT RELIEVE TEACHING PHYSICIAN DOCUMENTATION REQUIREMENTS:

As the electronic signature system in being implemented, please be aware that electronically signing a document does not relieve a teaching physician from the responsibility of completing appropriate teaching physician documentation and ensuring that documentation is contained in the patient's medical record.

In short, the teaching physician editing the resident's dictation on-line and then electronically signing IS NOT sufficient.

The most common way residents and teaching physicians work together is the resident sees the patient first, and then is either followed or joined by the Teaching Physician.   If this is how you see patients, here are the three options:

OPTION ONE:

1) the Teaching Physician may dictate the note that supports the service himself/herself.

OPTION TWO:

2) when the appropriate criteria is met (> 50% of face-to-face time with/pt in counseling or coordination of care) the Teaching Physician may bill based on time.

or

OPTION THREE:

3) the Teaching Physician  must personally document in writing or by dictated note his/her participation in the three key components of these services -- history, physical examination, and medical decision making.  If the teaching physician is repeating key elements of the service components obtained previously and documented by the resident, (e.g., the patient's complete history and physical examination) the teaching physician need not repeat the documentation of these components in detail.   Rather, the documentation of the teaching physician may be brief, summary comments that tie into the resident's entry and which confirm or revise the key elements defined as:

relevant history of present illness and prior diagnostic tests;

major findings of the physical examination;

assessment, clinical impression or diagnosis; and

plan of care.

Therefore, the documentation of the key elements above may be satisfied by the combination of entries into the medical record made by the resident and the teaching physician.    (Note: Except for the primary care exception: the teaching physician must be physically present during, or personally perform, the portions of the E & M service that determine the level of service billed.)

An acceptable note documenting the Teaching Physician's participation would read: "The history as documented by Dr. Resident was confirmed with the patient.  It is noted that (add remarks to History, Past Family and Social history {PFSH} or Review of Systems {ROS}... My exam confirms or revises... Diagnostic Tests and/or X-rays   performed or reviewed show... I confirm/revise the assessment and diagnosis of ... and agree/revise  the  resident's plan of care as follows... (see Resident's notes for further details)."

----- NOT GENERALLY AN OPTION -----

Please note the following note is ONLY appropriate only when the resident and teaching physician see the patient together for the entire service and the resident does not see the patient separately at any time  - "I was present during all activities documented above, agree with the above documentation, and  participated in the entire history, physical examination, medical decision making and counseling of this patient."

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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