SUPERVISION OF RESIDENTS / FELLOWS
POLICY:
It is the policy of <Facility Name> to provide a program that will allow residents and/or
fellows to participate in a rotation with members of the Medical Staff.
PROCEDURE:

All residents and/or fellows, must be affiliated with a residency program approved
by the Governing Body and shall make application through the Teaching Institution.

Each resident and/or fellow must provide required documentation prior to
participation in patient care at <Facility Name>.

Communication shall occur between the Teaching Institution and the facility, which
includes the Medical Advisory Committee (MAC), Governing Body, Administrator,
Clinical Director and sponsoring physician.

Residents and/or fellows, must work under supervision of sponsoring licensed
independent practitioners who have been granted clinical privileges that reflect the
patient care responsibilities assigned to residents and/or fellows, through the
medical staff process; these will be in accordance with guidelines required by the
accrediting bodies such as The Joint Commission, AAAHC, and the Accreditation
Council on Graduate Medical Education. Supervision is defined as being physically
in the facility. Residents and/or fellows, may not be appointed to the Medical Staff
and cannot vote or be appointed to committees. Academic and disciplinary
procedures for residents and/or fellows will be in accordance with protocols
developed in accordance with the Teaching Institution's residency advisory
committee and the appropriate Medical Staff committees of the facility.

Written descriptions of the role, responsibilities and patient care activities of
participants in professional graduate education programs are provided to the facility
MAC and sponsoring licensed independent practitioner; the MAC will review and
revise job descriptions to be facility specific.

Each resident and/or fellow may be allowed to write orders, record progress and
operative notes, H&P’s and other authorized duties as outlined in the job description
and allowed by law. All entries made by the resident and/or fellow will be cosigned
by the sponsoring physician.

Each Teaching Institution will provide a list of residents and/or fellows prior to their
rotation. The information shall include the medical license number, state narcotic
license, DEA number, photo ID, DOB, level of postgraduate training and a
statement attesting that the resident and/or fellow is in good standing at the
institution and is covered by the program’s liability policy.
SUPERVISION OF RESIDENTS / FELLOWS

The resident and/or fellow shall be required to wear identification that identifies
them as a resident and/or fellow, and must be introduced to the patient as a
resident and/or fellow, prior to the provision of any patient care.

All names of residents and/or fellows doing a rotation with <Facility Name> should
be reported and documented in the MAC minutes.

This policy does not apply if a resident and/or fellow is an observer only (does not
touch a patient, document/record in the chart or advise the patient).