Rounding, Attestations & Billing, Transitions

Rounding

Golden Rule:  The resident shall not spend >50% of his/her/their day rounding

Weekday rounds should occur from 8:15AM-11AM

Weekday Afternoon Rounds

• Attending to touch base with Consult Sr in afternoon

• Occur on a PRN basis only when deemed necessary by Consult Sr and attending

• The purpose of afternoon rounds is staffing consults with an urgent clinical need

  • Avoid rounding for sole purpose of “shrinking the list”, i.e. each consult should still get appropriate vetting and assessment

• Should not occur earlier than ~3:30PM, nor later than ~6PM

• Should not exceed 2 hours in length

• Allow for team member fluidity – not all members required

Weekend Rounds

• Start at 8AM

• Adjust rounding structure, length, and expectations for resident learner

  • PGY-2 “off service”: will be less familiar

  • On Call: End rounds prior to 11AM

Independent Bedside Rounding

• Highly encouraged for follow up patients with relatively lower learning potential

• Should be utilized for any patients that need to be seen after 11AM

Attestations & Billing

All inpatient notes should be co-signed by the attending on the same day of the attending encounter. Hospital teams require timely updates.

Time Based Billing

• This is infallible for higher levels of billing when you’ve spent significant time on a case.

  • " I spent a total of *** minutes reviewing history of the present illness, reviewing laboratory and imaging studies, elaborating a treatment plan, counseling, and coordinating care”

  • Rounding IS considered part of patient care

• Easier for coder to bill for the appropriate level of care

Complexity of Medical Decision Making Billing

• For complex patients, it is critical to review the resident’s notes for necessary elements to confirm higher level of medical decision making.

Medical Student Notes

• MS3 students should write notes for practice, but resident is responsible for notes for billing purposes

• MS4 and sub-I students should write notes for patient care and billing purposes

  • Extra attention must be paid to the contents of the note

  • An attestation is critical in a timely fashion

• Medical Student Note Billing — Resident Handbook (squarespace.com)

Transitions

It is not appropriate to say “This is my first day on service, I’m unfamiliar with the patient” for an A+ neurology consult service.

A verbal and/or written handoff should occur on Thursday afternoon/evening with incoming attending.

Faculty handoffs should include team reviews

• Team compilation (residents, interns, students)

• Learner strengths and areas for improvement

• Goals set by the team/individuals to continue to monitor

Faculty handoffs should include patient specific details

• Active patient alerts with anticipatory plans of care

• Goals of care discussions pending

• Patients not yet seen by attending

• Reason for consult, notable workup, ddx , and pending action items should be discussed  for active patients

For any patient not discussed during verbal handoff, incoming attending should review EMR to familiarize themselves with all patients.

• Avoid relying on the residents to “catch you up” on rounds

If the weekend resident is the “off -service” PGY-2, discuss “to do” list for each patient over the weekend with consult senior

• Include patients to be seen prior to rounds, together on rounds, or chart reviewed only