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Note and Documentation Requirements (Inpatient)

Page history last edited by gabrielpalley 2 months, 3 weeks ago

FM IPS attending attestations

Created: 12/4/2020

 

Attestations for trainees have evolved and changed and below are the currently recommended attestations for resident and student notes. Please note that you do not need to be much, or any, details into these attestations. The implication is that by adding these attestations and then signing the note, we have read and edited the  note and they are now “our note.” So even for medical students, we do not need to repeat a physical exam or an Assessment and Plan. 

 

APP notes are fundamentally different, and are described below. 

 

1. H&P

 =attest_H_P_resident

 

ATTENDING HISTORY AND PHYSICAL ATTESTATION:

I personally saw and evaluated (patients name automatically imported) on _ [date attend saw pt]. The case was discussed on rounds with the resident. I personally reviewed the HPI, PH, FH, SH, ROS and medications. I repeated pertinent portions of the examination and reviewed the relevant imaging and laboratory data. I agree with the findings, assessment and plan as documented. At this time, based on the patient’s current clinical condition and treatment, I expect the patient to remain in the hospital two midnights or more ▼( two midnights or more/less than 2 midnights).

 

2. D/C summary

=attest_resident_discharge_summary

 

ATTENDING DISCHARGE ATTESTATION:

I have seen and examined the patient on the date of discharge. I have reviewed, edited, and agree with the above discharge summary. I personally spentmore than 30 minutes▼(more than 30 minutes/less than 30 minutes) was on coordination of care, face-to-face counseling, and preparation of discharge▼(discharge/transfer) documentation.

 

3. Progress Note/Consult Note

=attest_resident_prognote

 

ATTENDING ATTESTATION OF RESIDENT NOTE:

I saw and examined the patient on the above date of service and discussed the care with the resident. I agree with the findings and plan in the note above and have edited the documentation to reflect my findings and plan.

 

 

4. Patient Not Seen - (Please note that we will not be able to bill for this day when this attestation is used)

 

=attest_resident_note_pt_not_seen

 

ATTENDING ATTESTATION OF RESIDENT NOTE:

I agree with the findings and plan in the note above and have edited the documentation to reflect my findings and plan. I did not see this patient on this date.

 

5. Student (Medical student, APP student) without Resident

 

=attest_attending/app_sup_student

 

I, Gabriel Palley, was present with and supervised the student who documented elements of this note including the medical history, the physical exam, and/or medical decision making. I performed and verified the entire exam and participated in all aspects of the medical decision making process as documented. I have verified, edited as necessary, and agree with documentation or findings including history, physical exam, and/or medical decision making.

 

6. Student (Medical Student, APP student) with resident

=attest_attending_sup_studentandresident

 

I, Gabriel Palley, discussed the case with the resident▼(resident/resident and student).  I performed and verified the entire exam and participated in all aspects of the medical decision making process as documented. I have verified, edited as necessary, and agree with documentation or findings including history, physical exam, and/or medical decision making.

 

7. APP attestation (To be used for H&P, Progress notes, and DC summaries)

This is a “shared billing” attestation and is fundamentally different from attestations for trainees (residents or medical students) notes. When we put attestations on trainee notes, they are fundamentally “our” note and the attestation is stating that you have read the entire note and agree and are willing to sign your name to it.  For APPs, in order to be able to bill for “shared billing”, the attending needs to include some detailed information about the patient in the “and find _” section. We are putting our input in addition to the completed APPs note. There is not yet a pre-made “=” phrase, so please copy this and use it as a template. 

 

ATTENDING ATTESTATION OF APP NOTE:

Clinical Date of Service: _

I personally saw _ face to face and find _. Key portions of the encounter were reviewed and I agree with the diagnosis and management documented by PA▼(PA/NP) _, whose note is available above for further detail.

 

Dr _ was the upper level resident present and involved in the decision making on the team.

 

(Your Name)

 

 

 

 

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