Supervision of Residents
Residency training is an educational experience designed to offer residents the opportunity to participate in the clinical evaluation and care of patients in a variety of patient care settings.  All aspects of patient care rendered by resident physicians must receive close supervision.

All aspects of patient care are ultimately the responsibility of the attending physician and involved consultants.  Attending physicians have the right to prohibit resident participation in the care of their patients without penalty, and when allowing care of their patients by residents do not relinquish their rights or responsibilities to: examine and interview, admit or discharge their patients; write orders, progress notes, and discharge summaries; obtain consultations; or to correct resident medical record entries deemed to be erroneous or misleading by crossing through the erroneous statement and initialing the change.

When a resident is involved in the care of a patient, it is the resident’s responsibility to communicate effectively with their supervising physician regarding the findings of their evaluation, physical examination, interpretation of diagnostic tests, and intended interventions on a continuous basis.

The attending physician and consulting physicians must review all entries by house staff in the medical record on a daily basis and make any necessary corrections in the entries. Attending and consultant physicians must document that they have personally performed the key components of each medical encounter in order to maintain compliance with guidelines for teaching physicians.

The goal of residency training is to develop resident physicians into independent practitioners by allowing increasing responsibility in the assessment of patients and the development and implementation of therapeutic strategies. However, it remains the responsibility of all participating staff physicians to closely supervise house staff in the care of patients.  House staff must always notify the appropriate attending or consulting physicians of any change in a patient’s condition or prior to initiating changes in a patient’s treatment.

Levels of Supervision:
To ensure oversight of resident supervision and graded authority and responsibility, the level of supervision is classified as per the guidelines set by ACGME for General Surgery.

a) Direct Supervision:  the supervising physician is physically present with the resident and patient.
b) Indirect Supervision:

1) With direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available   to                provide Direct Supervision. 

(2) With direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision. 

(3) Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. 

The policy for supervision of residents addressing resident responsibilities for patient care, progressive responsibilities for patient management and faculty responsibility for supervision are outlined below (with separate notes for PGY I residents)

  1. Admission History and Physicals/Consultations/Pre-operative evaluation/Post-operative management/transfer of patients/discharge of patients and interpretation of laboratory results: 

Residents may perform history and physical examinations, and consultations under indirect supervision with direct supervision available.  It is the responsibility of the resident to discuss their findings with the attending physician upon completion of their examination. The attending physician must confirm the key portions of the history and physical exam, make additions and corrections in the documented history and physical, and co-sign the resident’s documentation.  It is the attending physician’s responsibility to document within the appropriate teaching physician guidelines.

Residents may perform pre-operative evaluation work up and formulation of a plan of treatment under indirect supervision with direct supervision available. It is the responsibility of the resident to present the plan to the attending physician. It is the responsibility of the attending physician to ensure the accuracy of the documentation and the appropriateness of the planned operative approach. 

Residents may perform management of routine post-operative issues such as fluid management, decisions of venous thromboembolism prophylaxis etc. under indirect supervision with direct supervision available. It is the responsibility of the resident to update the attending physician. It is the responsibility of the attending physician to oversee all aspects of the post-operative management. 

Residents may undertake activities related to discharging a patient, transferring a patient under indirect supervision with direct supervision available only after prior review and approval by an attending physician. 

Residents may interpret radiology and laboratory results with oversight and communicate the results to the attending physician. 

For PGY I residents: Direct supervision is required until competency is demonstrated for: 

1.         Patient Management Competencies 

a)      Initial evaluation and management of patients in the urgent or emergent situation, including urgent consultations, trauma, and emergency department consultations (ATLS required) .

b)      Evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrhythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartment syndromes .

c)      Evaluation and management of critically-ill patients, either immediately post-operatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing, and other treatments. 

d)      Management of patients in cardiac or respiratory arrest (ACLS required) 

PGY I residents can undertake these tasks after verification of competency. A curriculum to enable verification of competency has been established at our program. This curriculum consists of a) Completing the Fundamentals of Surgery curriculum, b) didactic session that goes over all the clinical scenarios that require direct supervision, c) a quiz to test adequacy of knowledge in all areas that require direct supervision. Only after the PGY I residents satisfy all these requirements, they can perform these activities. In addition PGY I residents are required to sign at least 10 page cards per month that document the day, date, service, reason paged for, action taken and who supervised them. These cards are signed by the Program Director.     

  1. Daily Progress Notes: 

Residents may evaluate patients and write daily progress notes under indirect supervision with direct supervision available.  It is the responsibility of the resident to discuss their findings and treatment plans documented in their progress note with the attending physician on a daily basis, or more often as described above, when a patient’s condition changes, or prior to initiating changes in a patient’s treatment.  The attending physician must perform the key portions of the exam and confirm the resident’s documentation in the progress note on a daily basis to maintain compliance with documentation guidelines for teaching physicians.  Attending and consulting physicians must make additions and corrections in the daily progress notes and signify these with initials and a date and time of the additions to the medical record.  All documentation by house staff and attending physicians must be legible to those who use the medical record, including signatures. All entries must be dated and signed. 

  1. Daily Orders:

Residents may write daily orders on patients for whom they are participating in the care under indirect supervision with direct supervision available or oversight. These orders will be implemented without the co-signature of an attending or consulting physician.  It is the responsibility of the resident to discuss their orders with the attending or consulting physician.  Attending and consulting physicians may write orders in the patient’s chart on all teaching cases.  Residents should notify the appropriate nursing or support staff of orders entered into the chart to facilitate timely patient care.  Residents are encouraged to evaluate all patients for whom they are initiating orders.  However, if it is clinically appropriate, residents are allowed to place ”verbal” orders over the phone.  All phone orders must be signed, dated, and timed within 24 hours. 

  1. Performance of Procedures 

Procedures in the operating room: Residents at all levels must and will be directly supervised by the physical presence of the attending physician during all operative procedures performed in the operating room. The policy of the University prohibits taking the patient to the operating room without the physical presence of the attending physician.  The extent of participation by the resident in the procedure is at the discretion of the attending physician.  The patient’s attending physician must be notified before informed consent is obtained from the patient or the appropriate individual representing the patient. 

Minor procedures outside the operating room: Minor procedures performed at other locations (i.e. ward, clinic, emergency room, intensive care unit) may be performed by the appropriate level resident under indirect supervision with direct supervision immediately available or direct supervision available along with the attending physicians knowledge and approval. Senior residents may supervise PGY I and intermediate level residents that are not yet qualified in a given procedure. Levels of qualifications for procedures are as listed below. 

Procedures 

                                                                                    PGY 2    PGY 3   PGY 4    PGY5

1.         Paracentesis                                                          x             x              x          x  

2.         Arterial Catheterization                                           x             x              x          x         

3.         Central venous catheter insertion                            x             x              x          x         

4.         Endotracheal intubation                                         x             x              x          x         

5.         Femoral line insertion                                             x             x              x          x         

6.         Foley catheter insertion                                          x             x              x          x         

7.         Lumbar puncture                                                   x             x              x          x

8.         Nasogastric intubation                                           x             x              x          x

9.         Peripheral venous access                                       x             x              x          x 

10.       Repair  simple laceration                                        x             x              x          x

11.       Repair complex laceration                                      x             x              x          x

12.       Wound debridement                                              x             x              x          x

13.       Skin biopsy                                                           x             x              x          x

14.       I & D abscess                                                       x             x              x          x

15.       Anoscopy/proctoscopy                                         x             x              x          x

16.       Insert chest tube                                                    x             x              x          x

17.       Thoracentesis                                                        x             x              x          x

18.       Aspiration fluid collection                                       x             x              x          x

19.       Swann Ganz Catheter Insertion                              x             x              x          x         

For PGY I: All minor procedures for PGY I are performed under direct supervision by a senior resident or attending physician. This includes procedures such as placement of central venous access lines, thoracostomy tube insertion, intubation, paracentesis, excision of minor lesions etc. Some procedures can be performed under indirect supervision with direct supervision available after verification of competency. These procedures include: repair of surgical incisions of the skin and soft tissues, repair of skin and soft tissue lacerations and bedside debridement.

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