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Ask the expert: How should teaching physicians document resident supervision to avoid billing fraud?

Residency Program Connection, April 10, 2007

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The teaching physician should not overwrite the resident's consultation report, narrative, or template note, or write in the columns or margins above, below, or beside the resident's documentation. Instead, the teaching physician should document a separately dated and signed narrative progress note or consultation form, placed in chronological chart order, linking to the resident's documentation. When templates are used, especially in certain specialties, they should be designed to support separate resident and teaching physician documentation and allow for each to be individually dated and signed. When more than one resident documents in the chart on the same day, the teaching physician should identify the resident to whom he/she is linking by name or specialty.

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