documentation

when an attending is writing their tie-in note, it should start out with "pt seen and examed..agree with the above resident note"...etc etc..and then add any new events and plan for the day..I am seeing attending notes as follow "pt. seen and exam, repeat ct abd pelvis..PT to evaulate, advance to reg.diet...blah blah..

face-face

There must be documentation that the patient was face-to-face with physician, example; •Admitting note: “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.”
•Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.” The Teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The Teaching physician’s note should reference the resident’s note.

documentation

and if that is not done and they bill a level 2 99232 or even a 99233, their note really don't support the level code? OMG..when will the get it..