InterCare Community Health Network
RESIDENTS, DOCUMENTATION POLICY
Manual: PATIENT CARE, TREATMENT, AND SERVICES
CHAPTER: RECORD OF CARE
SECTION: STUDENTS
ORIGIN DATE: DECEMBER 2012
REVIEW DATE: DECEMBER 2013
PURPOSE: InterCare strives to assist in the training of medical residents. In doing so, it is our intention
to adhere to all teaching physician requirements necessary for compliant billing. The Evaluation and
Management services billed require a specified level of supervising physician presence and well as
documentation.
POLICY:
Presence Requirements:
The minimum requirements for a teaching physician are the following:
 The service(s) performed by the teaching physician or the teaching physician’s physical presence
during the key or critical portions of the service performed by the resident.
 The participation of the teaching physician in the management of the patient
(Physically present is when the teaching physician is located in the same room as the patient and/or
performs a face-to-face service.)
Documentation Requirements
The teaching physician must document a statement attesting to his/her presence and participation. This
is known as a linking statement.
The combined documentation of the resident and the teaching physician constitutes the documentation
for the service and together must support the medical necessity.
Examples of linking statements:
Sufficient I saw and evaluated this patient. I reviewed the resident’s note and agree that picture is more
consistent with pericarditis than myocardial ischemia. Agree with resident’s plan to begin
NSAIDS.
 I saw and evaluated the patient. Agree with the resident’s note, but lower extremities are not
weaker. Will not do MRI of L/S spine at this time
Insufficient
 Agree with above.
 Discussed with resident. Agree
 Pt seen and evaluated.
PROCEDURE:
Training time in the EHR will be approximately 8 hours. More will be scheduled if needed.
All documentation will be performed in InterCare’s Electronic Health Record.
When those patients seen by the resident are screened, the clinical staff will indicate the resident
physician in P-L-P-D. (Patient-Location-Provider-Date)
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InterCare Community Health Network
RESIDENTS, DOCUMENTATION POLICY
Manual: PATIENT CARE, TREATMENT, AND SERVICES
CHAPTER: RECORD OF CARE
SECTION: STUDENTS
ORIGIN DATE: DECEMBER 2012
REVIEW DATE: DECEMBER 2013
The resident will document on the SOAP note all the contents necessary for the management of the
patient.
The resident will indicate the request for review of the encounter by checking the box under ‘Physician
sign off request’ on the Finalize OV tab. This will prompt a task assignment to the teaching physician’s
inbox.
The teaching physician will review/edit the contents focusing primarily on the SOAP and Check Out tabs
as well as the Order Management Summary.
A linking statement will be documented in the ‘Plan’ comments portion of the SOAP tab.
Billing
The supervising physician will complete the coding and billing submission from the Finalize OV tab,
including the ‘Supervising physician sign off’. This will prompt the generation of the Master IM.
All Master IMs will be sent to the Provider Approval Queue of the teaching physician for electronic
signature.
References:
Revision Dates:
CMO Approval Date:
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