Medicare Teaching Physician Regulations
(Summary)

Medicare Teaching Physician Regulations
(CMS Document)

Medicaid Teaching Physician Rules

Example Documentation

1995 E&M Guidelines Audit Tool

Good Documentation

Poor Documentation

Example Documentation for Teaching Physicians

When documenting the attending note, choose the appropriate scenario: either you saw the patient with the resident present or without the resident present.

Example 1:

I saw the patient with Dr. Resident. I interviewed the patient. History and exam were reviewed and confirmed as described above. Briefly, my key findings for history are:____________. My key findings for exam are:________________________. The assessment and plan were reviewed and I confirm/revise the following: _______________________. See Resident note for details.

Example 2:

I saw the patient without Dr. Resident. I interviewed the patient. History and exam were reviewed and confirmed as described above. Briefly, my key findings for history are:____________. I repeated the exam and my key findings for exam are:________________________. The assessment and plan were reviewed and I confirm/revise the following: _______________________. See Resident note for details.

Remember: Not documented, not done!

Back to top

Sample of Good Documentation

The MD performed and documented the history, exam and medical decision making. The document is legible.

(Click on Image)

Back to top

Sample of Poor Documentation

There is no chief complaint. The clinical impression is not clear.

(Click on Image)

Back to top

Sample of Good Teaching Physician Documentation

The MD has confirmed each of the key findings in the appropriate section of the template. The MD has checked the appropriate teaching physician statement. It is clear that the MD performed the service and documented it.

(Click on Image)

Back to top

Sample of Poor Teaching Physician Documentation

The MD did not state the history and perform the key portions of the exam; "agree" is insufficient documentation. The decision making is documented. This level of service requires all three elements for billing.

(Click on Image)

Back to top