Resident Supervision

General Principles
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. 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. However, it remains the responsibility of all participating staff physicians to closely supervise residents in the care of patients.

The program and teaching faculty are responsible for providing appropriate volume and complexity of clinical opportunities. They are responsible for the evaluation of resident performance, with appropriate feedback to the resident. They will assist in the development of positive relationships toward patients, medical students, peers, ancillary medical personnel, and teachers. Faculty members are responsible for serving as positive role models for the residents. In their supervisory capacity they create an environment of graduated responsibility for the residents, while providing excellent patient care, honoring specific contracts with financial providers, and implied contracts for care with patients.

All aspects of patient care are ultimately the responsibility of the attending physician and involved consultants. Attending physicians have the right to limit resident participation in the care of their patients, 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. Residents must always notify the appropriate attending or consulting physicians of any change in a patient's condition prior to initiating changes in a patient's treatment.

The attending physician and consulting physicians must review all entries by residents 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.

Patient Care Settings

Admission History and Physicals/Consultations
Residents may perform history and physical examinations, and consultations without the attending physician being physically present. 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.

Daily Progress Notes
Residents may evaluate patients and write daily progress notes without the attending physician being physically present. 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.

Daily Orders
Residents may write daily orders on patients for whom they are participating in the care. These orders will be implemented without the co-signature of an attending or consulting physicia. 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.

Performance of Procedures
Residents will be supervised by the physical presence of the attending physician during all operative procedures performed in the operating room. 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.

Clinic
Residents will evaluate patients in the outpatient clinics under the supervision of the responsible attending surgeon. The level of supervision and documentation required will vary with the clinical condition of the patient.

Emergency Department
All patients evaluated in the emergency department must be discussed with the responsible attending surgeon. The attending surgeon must concur with the planned disposition and will personally evaluate the patient at their discretion. Consultation notes will be completed at the time of the evaluation.