medical staff, shall have the authority to write orders and progress notes without the co-signature of the attending or supervising physician. Consultations, Operative Reports, Emergency Department Reports, and Histories and Physicals prepared by APPs must be co-signed by the attending physician within twenty-four( 24) hours. All Discharge Summaries prepared by Allied Health Professionals must be co-signed by the attending physician within 24 hours of discharge. It is noted that a physician may not supervise more than three( 3) Allied Health Professionals at any one point in time.
APPs practicing independently do not require co-signature of their notes.
5. Residents and Fellows. Residents and Fellows when practicing within their scope of practice, and as authorized by the Residency Supervisory Committee,( Medical Staff Committees refers to Residents, Fellows and Students Committee) and acting under the supervision of a Medical Staff Member, shall have authority to write orders and progress notes without the co-signature of the attending or supervising physician. Consultations, Operative Reports, Emergency Department Reports, and Histories and Physicals prepared by Residents and Fellows must be co- signed by the attending physician within twenty-four( 24) hours. All Discharge Summaries prepared by Residents and Fellows must be co-signed by the attending physician within 24 hours of discharge.
6. Summary of Documentation Timelines.
Document Due within EMR
Signature Due Date H & P 24 Hours 24 Hours
Progress Notes Daily Daily Brief Op
Immediately following surgery before the patient transfers to the next level of care.
Before patient moves to the next level of care.
Op Report 24 Hours After Surgery 24 Hours After Surgery
Consults 24 Hours 24 Hours Discharge Summary 24 hours after discharge 24 hours after discharge
7. Dated / Timed. All entries must be dated and timed. All documentation of care should include the time using the 24-hour clock.
8. Abbreviations.
a. When Allowed. During the course of care and treatment of a patient, Members may use abbreviations in all parts of the medical record of a patient. Only standardized terminology, definitions,
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