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Attending Attestation Template

Page history last edited by Kendall Rogers 11 months, 3 weeks ago

This document was created by Kendall Rogers in January 2017. The original document is under the "Division" folder.  I have copied and made some modifications for easy access.

 

Examples of attendings attestations for documentation:

 

Suggested name for autotext: 

.hx 

History and Physical by Resident 

ATTENDING ADDENDUM:

I saw and evaluated M on .  The case was discussed on rounds with . I personally reviewed the HPI, PH, FH, SH, ROS and medications. I repeated pertinent portions of the examination and reviewed the relevant imaging and laboratory data. I agree with the findings, assessment and plan as documented. At this time, based on her current clinical condition and treatment, I expect the patient to remain in the hospital less than one day, less than 2 days, more than two days.  KR

 

.res 

Progress Note by Resident:

ATTENDING ADDENDUM OF RESIDENT NOTE:
I saw and evaluated the patient on the above date of service and discussed the care with the resident. I agree with the findings and plan as documented in the note above and have edited it to reflect my findings and plan. KR

 

.notseen 

Patient discussed but not seen (MICU transfers)
ATTENDING ADDENDUM OF RESIDENT NOTE:
I agree with the findings and plan as documented in the note above and have edited it to reflect my findings and plan. I did not staff this patient on this date.  KR

 

.prolonged

Prolonged Services Addendum

I saw and evaluated the patient on the above date of service. I reviewed all the medications, vital signs, labs and imaging.

Patient is a (assessment statement, with diagnoses and why patient is hospitalized)

I personally spent ( for prolonged service, the time spent with pt needs to be over 30 ) minutes on the medical floor coordinating care and face to face time counseling the patient, >50% of this time was spent on counseling and coordination of care. I counselled the patient on , and coordinated care with ****

 

Discharge Summaries:

.dx 

Discharge less than 30 minutes:
ATTENDING ADDENDUM: I have seen and examined the patient on their discharge day.  I have reviewed, edited, and agree with the above discharge summary.  I have electronically signed this document. KR

 

.30 

Greater than 30 minute discharge: 

ATTENDING ADDENDUM: I have seen and examined the patient on their discharge day.  I have reviewed, edited, and agree with the above discharge summary.  More than 30 minutes was personally spent on discharge planning on the day of discharge in coordination of care,  counseling the patient, and preparation of discharge and transfer paperwork.  I have electronically signed this document. KR

 

.notseen 

ED Patient discussed but not seen: 

ATTENDING ADDENDUM OF RESIDENT NOTE:
This patient was seen overnight by the resident and I did not see or evaluate the patient before discharge from ED. I discussed the care with the resident and my understanding is that the ED was in agreement with this plan. I agree with the plan as described above per my discussion with the resident. KR

 

NP/PA Documentation: 

.np 

ATTENDING ADDENDUM OF NP/PA NOTE:
I saw and evaluated the patient and discussed the care with (name of NP or PA) above on (date). I agree with the findings and plan as documented in the note above. (then you must add something here about what you personally added to this encounter to get credit for split/shared billing) KR

 

.npnotseen 

Patient discussed with NP/PA but not seen
ATTENDING ADDENDUM OF NP/PA NOTE:
I discussed the care with the NP/PA and agree with the findings and plan as documented in the note above.  I did not staff this patient on this date.  KR

 

APP H&P

ATTENDING ADDENDUM:

I saw and evaluated M on .  The case was discussed on rounds with . I personally reviewed the HPI, PH, FH, SH, ROS and medications. I repeated pertinent portions of the examination and reviewed the relevant imaging and laboratory data. I agree with the findings, assessment and plan as documented. At this time, based on her current clinical condition and treatment, I expect the patient to remain in the hospital less than one day, less than 2 days, more than two days. (then you must add something here about what you personally added to this encounter to get credit for split/shared billing) KR

 

APP Discharge <30 min

.dx 

Discharge less than 30 minutes:
ATTENDING ADDENDUM: I have seen and examined the patient on their discharge day.  I have reviewed, edited, and agree with the above discharge summary.  I have electronically signed this document. (then you must add something here about what you personally added to this encounter to get credit for split/shared billing)KR

 

APP Discharge >30 min

.30 

Greater than 30 minute discharge: 

ATTENDING ADDENDUM: I have seen and examined the patient on their discharge day.  I have reviewed, edited, and agree with the above discharge summary.  More than 3o minutes was personally spent on discharge planning on the day of discharge in coordination of care,  counseling the patient, and preparation of discharge and transfer paperwork.  I have electronically signed this document. (then you must add something here about what you personally added to this encounter to get credit for split/shared billing) KR


 

To bill for a note written by a resident/fellow, the Attending attestation must have: Date, indicate the patient was seen and evaluated, review and agreement with the resident note.  Some faculty like to put their initials at the end of their attestation. 

Acceptable examples:

 

Date:  /  /  .  Pt care discussed on rounds with team.  I have seen and evaluated the patient today.  I have reviewed the resident's note and agree with the findings documented.  In addition:

 

 

Date:  /  /  .  I have seen and evaluated the patient today.  I have discussed with the resident, then reviewed and edited the resident's above note to reflect my findings and the care plan.

 

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