Depending upon the clinical situation, four types of documentation of resident Refer to scenarios to Notes supervision are allowed: determine the appropriate 1. Attending 3. Co-signature 2. Attending addendum 4. Resident documentation type of documentation. Resident Supervision Attending Physician Responsibilities for Physician, Dental, Optometry and Podiatry Residents Emergency Department (ED) Telemedicine/ The ED attending must be physically present in “Supervising Practitioner” the ED and is the attending of record for all ED (synonymous with “Attending”): . The ED attending must be involved in the Responsible for all care in which interns, residents or disposition of all ED patients. fellows are involved. An independent note, addendum to the resi- “Resident” dent's note, or resident note with description of Please refer to the OAA Intranet for current refers to all physician, dental, optometry, and podia- attending involvement. Co-signature of resident recommendations and rules. try residents and fellows, regardless of training level. note by attending alone is not sufficient docu- mentation. • Real-time Videoconferencing: The attending “Documentation” must be in the general vicinity and available to is the health record entry that clearly demonstrates Observation Patients the resident for direct supervision without de- the involvement of the supervising ractitioner. The level of supervision depends upon the unit lay, as if the were being seen in a clinic. where the patient is being held (e.g. ICU, inpatient Four types of documentation of resident supervision: • Store and forward telehealth: The resident ward, or emergency department). Residents will 1. Attending’s progress note or other entry into reviews the material with or without the at- contact the attending on-call for patients being the patient health record. tending present, and the attending reviews the discharged before being seen by the attending. 2. Attending’s addendum to the resident admis- same material. The interpretations and reports sion or progress note. A summary of the discussion between the on all images and pathology specimens must 3. Co-signature by the attending implies that be verified by the attending. Residents must the attending has reviewed the resident note resident and Attending must be documented or other health record entry, and absent an in the resident’s note (for patients not seen by receive feedback on their interpretations. addendum to the contrary, concurs with the the attending prior to release). An independent • Home telehealth: Attendings are expected to content of the resident note or entry. Use of note or addendum to a resident note is required exercise general oversight of the care provided EHR function “Additional Signer” is not accept- when the attending evaluates the patient in by residents. Residents must consult with the able for documenting supervision and is not person. Co-signature of the note is not suffi- supervising practitioner regarding any changes the same as co-signature. cient. 4. Resident documentation of attending supervi- in a home telehealth patient’s status or pro- posed changes in the treatment plan. sion includes the name of the attending with Home Visits whom the case was discussed, a summary of Residents must have training in handling emergen- • Tele-ICU coverage (remote): The local ICU the discussion and a statement of the attend- cy situations and in-home health policies. PGY-1 attending is responsible for supervising resi- ings oversight responsibility (e.g., “I have seen dents-on-duty. Residents are expected to write and discussed the patient with my attending, residents must be accompanied by an attending. Dr. ‘X’, and Dr. ‘X’ agrees with my assessment For other PGY-level residents, the attending must all orders on patients whom they are covering. and plan” or “I have discussed the patient with be readily available via phone. Home visits must be Tele-ICU practitioners may act as consultants my Attending Dr. X and Dr. X agrees with my followed by a discussion between the attending to the residents, but not as their supervising ”), or at a minimum, the and the resident. practitioners. Veterans Health Administration responsible attending should be identified Office of Academic Affiliations Any of the 4 types of documentation is accept- (e.g., “The attending of record for this patient Any of the 4 types of documentation is VHA Handbook 1400.01 Resident Supervision able. encounter is Dr. ‘X’”)] acceptable www.va.gov/oaa/policies-and-agreements.asp Depending upon the clinical situation, four types of 1. Attending progress note 3. Co-signature documentation of resident supervision are allowed: 2. Attending addendum 4. Resident documentation Refer to scenarios to determine the appropriate type of documentation.

Outpatient: New Patient Visit (PGY-1) residents must have on-site supervision Consultations (Inpatient, Outpatient, Emer- Attending must write a pre-procedural note or Attending must be physically present in the clinic. at all times by either an attending or a more gency Department) an addendum to the resident's pre-procedure Every patient who is new to the facility must be advanced resident, with an attending being When residents are involved in consultation note describing findings, diagnosis, plan for seen by or discussed with an attending. available on-call. On-site supervision for PGY 1 services, the consultant attending is responsible treatment, and/or choice of procedure to be per- residents is required for Night Float and ‘Over for supervision of these residents. formed (may be done up to 30 days pre-op). May An Attending progress note, Attending’s adden- Cap’ Admissions. be combined with attending admission note or dum to the resident's note, or resident docu- Any of the 4 types of documentation is accept- addendum, if written in the timeframe specified mentation of attending involvement. Co-signa- Inpatient: Continuing Care able. in the Medical Center bylaws, not to exceed the ture of resident note by attending alone is not Attending must be personally involved in ongoing Radiology/Pathology end of the next calendar day after admission, or sufficient documentation. care. the day before the OR procedure. Use appropri- Outpatient: Return Visit Any of the 4 types of documentation, at a fre- Radiology or pathology reports must clearly ate note title. Informed Consent must be ob- Attending must be physically present in the clinic. quency consistent with the patient's condition identify the responsible supervising practitioner. tained according to VA policy. Attending level of involvement is documented in the VistA Surgical Patients should be seen by or discussed with an and principles of graduated levels of responsibil- Routine Bedside & Clinic (Non-OR) Procedure Package. Post-op documentation is per Joint attending at a frequency to ensure effective and ity and consistent with the medical staff bylaws. (e.g., LPs, central lines, centeses, I&D, skin biopsy) Commission requirements and local medical appropriate treatment. Complexity and risk dependent supervision and Inpatient: ICU Care center bylaws. Any of the 4 types of documentation is (includes SICU, MICU, CCU, etc.) documentation; principles of graduated levels of acceptable. Because of the unstable nature of patients in ICUs, responsibility apply. VistA Surgery Package Codes attending involvement is expected on admission • Level A: Attending Doing the Operation Attend- Outpatient: Discharge Resident writes procedure note that includes the and on a daily or more frequent basis. attending's name. Any of the 4 types of docu- ing performs the case but may be assisted by a Attending will ensure that discharge from a clinic resident. is appropriate. An admission note or addendum to the resi- mentation is acceptable. • Level B: Attending in OR, Scrubbed Attending is dent’s admission note is required within the Non-routine, Non-bedside, Non-OR Procedure physically present in OR / procedural room, and Any of the 4 types of documentation is timeframe specified in the Medical Center By- acceptable. (e.g., cardiac cath, endoscopy, invasive radiology) directly involved in the procedure. The resident laws, not to exceed the end of the next calendar The attending must authorize the procedure and performs major portions of the procedure. day after admission, including weekends and Inpatient: Admission be physically present in the procedural area. • Level C: Attending in OR, Not Scrubbed Attend- Attending must physically meet, examine and eval- holidays. Subsequent visits: Any of the 4 types of ing is physically present in OR / procedural room, Any of the 4 types of documentation: uate the patient within the time frame specified in documentation is acceptable. observes and provides direction to resident. the Medical Center Bylaws, not to exceed the end attending's name is required, and degree of Inpatient: Discharge or Transfer involvement is encouraged. • Level D: Attending in OR Suite, Immediately of the next calendar day after admission, including Attending must be personally involved in decisions Available Attending is physically present in OR / weekends and holidays. procedural suite and immediately available for to discharge or transfer the patient to another ser- Surgery / OR Procedures supervision or consultation as needed. An attending admission note or addendum to vice or level of care (including outpatient care). • Level E: Emergency Care Immediate care is nec- resident note documenting findings and recom- Attending independent note, co-signature of mendations regarding the treatment plan within essary to preserve life or prevent serious impair- the discharge/transfer note and/or the discharge ment. Attending has been contacted. the time frame specified in the Medical Center instruction note. If patient is transferred from Note: Emergency (non-elective) surgery with an Bylaws, not to exceed the end of the next cal- one service to another, the accepting attending endar day after admission, including weekends attending present should be coded as A-D with should treat the patient as a New Admission. If respect to the appropriate level of supervision. and holidays (e.g. I have personally assessed the same attending is responsible for the patient • Level F: Non-OR Procedure Routine bedside or the patient, reviewed the and across different levels of care, transfer docu- diagnostic studies, and agree with the resident’s clinic procedure done in the OR. Attending is mentation is not required. The Attending must Except in emergencies, the attending surgeon identified. assessment and plan). First post-graduate year co-sign a discharge summary. must evaluate each patient pre-operatively.