AAHPM Fall Quarterly 2011 : Page 7

FALL 2011 7 đŏ Initial or follow-up visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s find-ings and plan as documented in the resident’s note.” đŏ Follow-up visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.” đŏ Follow-up visit: “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker— now 3/5. There will be an MRI of L/S Spine today.” Examples of unacceptable documentation in any scenario include the following: đŏ “Agree with above” followed by legible countersigna-ture or identity đŏ “Rounded, reviewed, agree” followed by legible coun-tersignature or identity đŏ “Discussed with resident. Agree” followed by legible countersignature or identity đŏ “Seen and agree” followed by legible countersignature or identity đŏ “Patient seen and evaluated” followed by legible coun-tersignature or identity. These are unacceptable because they do not document that the TP was present, evaluated the patient, and/or had any involvement with the plan of care. All three ele-ments must be present in the TP note. Medical student documentation, other than review of systems and past family and social history, must be done in the physical presence of the TP or resident. The TP note may refer to the student documentation of ROS and/or past family and social history, but may not refer to medical student documentation of physical exam and/ or medical decision making. Even if these two elements were performed and documented by the medical stu-dent, they must also be performed and redocumented by the TP or resident physician. Reference 1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. www.cms.gov/Manuals/IOM/itemdetail. asp?itemID=CMS018912. Accessed August 18, 2011. Academic Palliative Medicine Physician Because of significant program expansion, the Section of Palliative Medicine at Dartmouth-Hitchcock Medical Center is seeking 2 palliative medicine physicians to join our interdisciplinary Palliative Care Service, currently comprised of 4 board certified Palliative Medicine physicians, 4 APRNs, coordinating RN, chap-lain, social worker, healing arts practitioners, and volunteer coordinator. We wel-come you to join an established and nationally recognized program with a fully accredited HPM fellowship program committed to promoting excellence in clin-ical care and education. We seek clinicians with a proven track record of sophis-ticated communication skills, expertise in symptom management, effective col-laboration within an interdisciplinary framework, and career interest in palliative care clinical practice and education. Responsibilities will include both inpatient and outpatient consultation and supervision of students, residents, and fellows. The successful candidates will join the Department of Anesthesiology with privi-leges at Dartmouth-Hitchcock Medical Center, membership in the Dartmouth-Hitchcock Clinic, and a faculty appointment at Dartmouth Medical School, with academic rank and compensation determined by experience and Dartmouth-Hitchcock Clinic policies. Board certification/eligibility in Hospice and Palliative Medicine is required, and fellowship training strongly encouraged. Dartmouth-Hitchcock Medical Center is a state-of-the-art academic medical cen-ter located in the Upper Connecticut River Valley of New Hampshire, a scenic set-ting in which to live and work. Outdoor activities and culture abound in this environment, which offers the opportunity to practice cutting edge medicine while enjoying the advantages of small town college life. Please send curriculum vitae and 3 letters of reference to: Sharona Sachs, MD, Director of Clinical Service c/o Sandra Knowlton-Soho, Practice Manager Sandra.Knowlton-Soho@hitchcock.org Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03756-0001 Dartmouth-Hitchcock Clinic is an affirmative action/equal opportunity employer and is especially interested in identifying female and minority candidates. www.Dartmouth-Hitchcock.org VOL. 12

Dartmouth-Hitchcock Medical Center
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