NP co-signing resident notes?

[eimaise]

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I am about to finish residency in 3 months and I am doing a clinic rotation right now. Sometimes, we go out into our university sub-specialty clinics for a half-day to see their patients for additional experience. Last week, I was in one hematology clinic and the attending was so busy during the session that she did not have the time to let me sign out a patient to her. She said, "well just sign out to x here" (who happens to be an NP). I did not like the idea and found it kind of insulting personally for several obvious reasons, but also considering this NP is new the hematology 7 months ago, I just did not like it at all, but I did as I was told. I noticed later the NP formally attested / co-signed my notes in the EHR saying the usual, "I agree with Dr. x and his assessment and plan." I did not know this was allowed actually... and I am also in a state where full NP supervision is required. Can anyone shed light on this for me?

 

[hallowmann]

NP's can't cosign our notes. That's ridiculous, it would essentially be meaningless (I agree with Dr, signed -X, Nurse Practitioner). I'm sure the NP got a kick out of it though. Honestly, I'm not sure they can even bill for that. In my program, in situations where an NP or a PA is involved, they simply can't use our notes in any way because of billing. They always have to restart a note that they get cosigned by the attending.

 

[eimaise]

NP's can't cosign our notes. That's ridiculous, it would essentially be meaningless (I agree with Dr, signed -X, Nurse Practitioner). I'm sure the NP got a kick out of it though. Honestly, I'm not sure they can even bill for that. In my program, in situations where an NP or a PA is involved, they simply can't use our notes in any way because of billing. They always have to restart a note that they get cosigned by the attending.

Thanks, that's what I figured, as it just seemed so backward. Very humbling as I have been moonlighting for the last year independently as a hospitalist and then have to be "supervised" by an NP in clinic. But also alarming from a legal / billing perspective too. Should I bring it up to someone you think?

 

[AdmiralChz]

Thanks, that's what I figured, as it just seemed so backward. Very humbling as I have been moonlighting for the last year independently as a hospitalist and then have to be "supervised" by an NP in clinic. But also alarming from a legal / billing perspective too. Should I bring it up to someone you think?

You’ve got 3 months left. This is ridiculous and allowing an NP to be a “pretending” is in large part illegal, but you are basically done. Let it go, maybe say something about it on your way out with diploma in hand.

 

[Piebaldi]

NP's can't cosign our notes. That's ridiculous, it would essentially be meaningless (I agree with Dr, signed -X, Nurse Practitioner). I'm sure the NP got a kick out of it though. Honestly, I'm not sure they can even bill for that. In my program, in situations where an NP or a PA is involved, they simply can't use our notes in any way because of billing. They always have to restart a note that they get cosigned by the attending.

Agreed in totality. Physicians sign NP/PA notes, not the other way around. Midlevels cannot sign physician notes, just as midlevels cannot hire physicians. This would be illegal, and likely criminal if billed to Medicare. I would report behavior like this.

 

[evilbooyaa]

You’ve got 3 months left. This is ridiculous and allowing an NP to be a “pretending” is in large part illegal, but you are basically done. Let it go, maybe say something about it on your way out with diploma in hand.

Agreed. I would laugh if somebody told me to 'sign out' to the NP/PA, unless it was in something I have ZERO experience in. I'm assuming you're a IM resident, so you've done multiple rotations in heme?

Regardless of signing out to a NP/PA, having them 'attest' your note is incredibly inappropriate and likely a reportable offense if you are so inclined. That being said, would mention it in passing to your PD (if supportive) or at graduation after diploma is in hand (if PD unsupportive).

 

[Piebaldi]

Thanks, that's what I figured, as it just seemed so backward. Very humbling as I have been moonlighting for the last year independently as a hospitalist and then have to be "supervised" by an NP in clinic. But also alarming from a legal / billing perspective too. Should I bring it up to someone you think?

They cannot bill if not cosigned by a physician, in this case, your attending. Yes you should bring it up. It is illegal for one, and if Medicare is made aware of this, poop will hit the fan. It is also unacceptable.

 

[ThoracicGuy]

They cannot bill if not cosigned by a physician, in this case, your attending. Yes you should bring it up. It is illegal for one, and if Medicare is made aware of this, poop will hit the fan. It is also unacceptable.

They can hurt you more.

 

[eimaise]

Agreed. I would laugh if somebody told me to 'sign out' to the NP/PA, unless it was in something I have ZERO experience in. I'm assuming you're a IM resident, so you've done multiple rotations in heme?

Regardless of signing out to a NP/PA, having them 'attest' your note is incredibly inappropriate and likely a reportable offense if you are so inclined. That being said, would mention it in passing to your PD (if supportive) or at graduation after diploma is in hand (if PD unsupportive).

Thanks for the advice. I told my PD and she said this was inappropriate and I should bring it to the attention of the department head, which I just did via email. We will see if anything comes of it. Agreed, it was insulting and humiliating given the amount of education, testing, and training we endure and then I am told to be "supervised" by someone who literally just decides to "change specialities" 7 months ago and overnight becomes a hematology expert. This must be stopped.

In other news, I actually emailed my local state congresswoman last week to let her know how strongly I disapprove of the current state house bill which would allow for full autonomous independent NP practice in my state. We will see if our politicians give a darn.

 

[Piebaldi]

Thanks for the advice. I told my PD and she said this was inappropriate and I should bring it to the attention of the department head, which I just did via email. We will see if anything comes of it. Agreed, it was insulting and humiliating given the amount of education, testing, and training we endure and then I am told to be "supervised" by someone who literally just decides to "change specialities" 7 months ago and overnight becomes a hematology expert. This must be stopped.

In other news, I actually emailed my local state congresswoman last week to let her know how strongly I disapprove of the current state house bill which would allow for full autonomous independent NP practice in my state. We will see if our politicians give a darn.

Let NPs practice independently. They will crash and burn quickly.

 

[AdmiralChz]

Thanks for the advice. I told my PD and she said this was inappropriate and I should bring it to the attention of the department head, which I just did via email. We will see if anything comes of it. Agreed, it was insulting and humiliating given the amount of education, testing, and training we endure and then I am told to be "supervised" by someone who literally just decides to "change specialities" 7 months ago and overnight becomes a hematology expert. This must be stopped.

In other news, I actually emailed my local state congresswoman last week to let her know how strongly I disapprove of the current state house bill which would allow for full autonomous independent NP practice in my state. We will see if our politicians give a darn.

You have some real cajones my friend. Good for you, and bravo.

 

[Raryn]

I can imagine maybe one circumstance where an NP "supervisor" would be appropriate - inpatient procedures where the NP has privileges but the resident doesn't (say, the NP has done 100 central lines but the resident has done few enough they aren't "signed off").

For anything else, I can't imagine this being OK.

 

[rokshana]

I am about to finish residency in 3 months and I am doing a clinic rotation right now. Sometimes, we go out into our university sub-specialty clinics for a half-day to see their patients for additional experience. Last week, I was in one hematology clinic and the attending was so busy during the session that she did not have the time to let me sign out a patient to her. She said, "well just sign out to x here" (who happens to be an NP). I did not like the idea and found it kind of insulting personally for several obvious reasons, but also considering this NP is new the hematology 7 months ago, I just did not like it at all, but I did as I was told. I noticed later the NP formally attested / co-signed my notes in the EHR saying the usual, "I agree with Dr. x and his assessment and plan." I did not know this was allowed actually... and I am also in a state where full NP supervision is required. Can anyone shed light on this for me?

If their notes need to be co-signed then they can’t co-sign your note for billing purposes...if your note isn’t being used for billing, then it doesn’t matter...butyou could always include that in your ACGME Eval

 

[michaelrack]

Agreed in totality. Physicians sign NP/PA notes, not the other way around. Midlevels cannot sign physician notes, just as midlevels cannot hire physicians. This would be illegal, and likely criminal if billed to Medicare. I would report behavior like this.

Midlevels can hire physicians

 

[wholeheartedly]

was this just a one patient, one time thing?

 

[eimaise]

You have some real cajones my friend. Good for you, and bravo.

Thanks. Got a reply from department head of hematology this morning saying this was unallowable and will stop immediately and no NP should be cosigning resident notes.

was this just a one patient, one time thing?

Basically has never happened to me in any outpatient setting in my entire residency (I'm med-peds so rotate through both departments of IM and peds). I don't think this is happening routinely, but I'm not sure. One time in the same department about a year or two ago, the attending was going to be late for rounds so he told the service NP to have the residents present to him. It was not good. But the attending got there about 15 minutes in and everything got better. That's it for me.

 

[Piebaldi]

Thanks. Got a reply from department head of hematology this morning saying this was unallowable and will stop immediately and no NP should be cosigning resident notes.



Basically has never happened to me in any outpatient setting in my entire residency (I'm med-peds so rotate through both departments of IM and peds). I don't think this is happening routinely, but I'm not sure. One time in the same department about a year or two ago, the attending was going to be late for rounds so he told the service NP to have the residents present to him. It was not good. But the attending got there about 15 minutes in and everything got better. That's it for me.

This is not an acceptable practice. At times NP/PAs can train you in things, or should you around, etc if they have been there for a awhile. But not in terms of knowledge, etc. Midlevels are people with limited experience and knowledge no matter how long they are in a position. It is also illegal to bill Medicare - physicians must co sign midlevel notes not the other way around. I would also see what to do specifically for any note co signed by a midlevel because Medicare will not look kindly on it.

 

[evilbooyaa]

Thanks. Got a reply from department head of hematology this morning saying this was unallowable and will stop immediately and no NP should be cosigning resident notes.

Glad you got an appropriate response, OP. Seems like a one-off thng that the department wants to stop.

 

[gutonc]

Glad you got an appropriate response, OP. Seems like a one-off thng that the department wants to stop.

It actually just sounds like one lazy/dips*** attending. Weaksauce and hopefully not an issue again.

 

[ortnakas]

I’m surprised the computer system even allowed for this? Our crappy EMR requires both resident and midlevel notes to be co-signed, but doesn’t allow either to co-sign notes for anyone else (a resident/midlevel can addend someone’s note I suppose, but it would still ultimately require an attending’s final signature).

 

[NotAProgDirector]

I can imagine maybe one circumstance where an NP "supervisor" would be appropriate - inpatient procedures where the NP has privileges but the resident doesn't (say, the NP has done 100 central lines but the resident has done few enough they aren't "signed off").

For anything else, I can't imagine this being OK.

Actually, this happens rarely in my program and it can be OK. If the NP has lots of experience in a specific field, for example. We have an inpatient diabetes consult team run by NP's -- they are amazing at dealing with complex insulin regimens, especially U-500 when it's needed. We also have an IV nutrition team in charge of all TPN run by an NP and pharmacist. Some subspecialty clinics have NP's that see the routine, non-operative cases -- Urology, for example, has NP's that see all the patients with lower urinary tract symptoms (men with BPH, women with incontinence and/or chronic cystitis). These can be great experiences for residents.

But the described situation isn't that.

It actually just sounds like one lazy/dips*** attending. Weaksauce and hopefully not an issue again.

I agree, sounds like a one time deal where someone made a dumb decision. I probably wouldn't have complained or done anything about it. The NP might have been super uncomfortable with the whole thing, but felt stuck too.

 

[Dr.LeoSpaceman]

But not in terms of knowledge, etc. Midlevels are people with limited experience and knowledge no matter how long they are in a position.

This is comment is shockingly short-sighted. Yes, training for APPs lacks the breadth of physicians. But what they can possess (especially those who have been in a position for a long period) is a depth of knowledge about specific things. That knowledge can certainly be helpful and informative, especially to residents.

Setting aside the issue of whether its appropriate or legal for APPs to co-sign notes, it's certainly inappropriate for physicians (especially residents) to approach them from the standpoint of "I'm the doctor, and my opinion my is worth more than yours."

 

[Piebaldi]

This is comment is shockingly short-sighted. Yes, training for APPs lacks the breadth of physicians. But what they can possess (especially those who have been in a position for a long period) is a depth of knowledge about specific things. That knowledge can certainly be helpful and informative, especially to residents.

Setting aside the issue of whether its appropriate or legal for APPs to co-sign notes, it's certainly inappropriate for physicians (especially residents) to approach them from the standpoint of "I'm the doctor, and my opinion my is worth more than yours."

Midlevels who can be in a position a long time might know about a specific thing in that setting - for example, Ortho PAs might be good at giving knee injections, etc. Most midlevels when you ask them specifics abou the how, why, etc are clueless. If you equate physician and midlevel knowledge, to me that is frightening.

 

[Dr.LeoSpaceman]

Midlevels who can be in a position a long time might know about a specific thing in that setting - for example, Ortho PAs might be good at giving knee injections, etc. Most midlevels when you ask them specifics abou the how, why, etc are clueless. If you equate physician and midlevel knowledge, to me that is frightening.

There is a 100% chance an experienced endocrine NP knows more about managing diabetes (for example) than I do as a surgeon. Thinking otherwise is hubris.

 

[Piebaldi]

There is a 100% chance an experienced endocrine NP knows more about managing diabetes (for example) than I do as a surgeon. Thinking otherwise is hubris.

I can respect that you feel that is true and correct. I will validate your thoughts.

 

[rokshana]

There is a 100% chance an experienced endocrine NP knows more about managing diabetes (for example) than I do as a surgeon. Thinking otherwise is hubris.

But not more than an IM resident for anything complicated with glucose management...they are very good at achieving a1c goal and inpt blood sugar goals for the vast majority of dm2 pts because they are good with the algorithms and can have more frequent contact, but have a pt with cfrd, u 500 needs, or dm that is not type 1or2 and ,no,they will not have the critical thinking skills to manage those pt...they are not supposed to ... their training is nursing not doctoring and just because they are a DNP does not make them a physician,period .

 

[rkaz]

I had a situation like this recently. I am a fellow, and one of the covering attendings noted that she was busy that day and asked if I would just have the DNP sign off on my note. I was taken aback (probably visible on my expression) and just said, "No, I think you should be the one signing off on my notes." The attending said "Ok."

I am glad I stood my ground. The funny thing is that during that rotation the DNP was the one who would ask my thoughts regarding medications etc, as she was new out of training, and I would be the one providing suggestions.

 

[Dr.LeoSpaceman]

Yeah,

But not more than an IM resident for anything complicated with glucose management...they are very good at achieving a1c goal and inpt blood sugar goals for the vast majority of dm2 pts because they are good with the algorithms and can have more frequent contact, but have a pt with cfrd, u 500 needs, or dm that is not type 1or2 and ,no,they will not have the critical thinking skills to manage those pt...they are not supposed to ... their training is nursing not doctoring and just because they are a DNP does not make them a physician,period .

Yeah, I get that. So turn it around for you: I am 100% sure I'd be more confident in my PA/NPs managing a post-op surgical patient than an IM resident.

And I never said an NP or a PA is a physician. But some of the comments about them belie a lack a basic professional respect for their knowledge and role.

 

[Raryn]

But not more than an IM resident for anything complicated with glucose management...they are very good at achieving a1c goal and inpt blood sugar goals for the vast majority of dm2 pts because they are good with the algorithms and can have more frequent contact, but have a pt with cfrd, u 500 needs, or dm that is not type 1or2 and ,no,they will not have the critical thinking skills to manage those pt...they are not supposed to ... their training is nursing not doctoring and just because they are a DNP does not make them a physician,period .

Maybe not some of the interns... 😉

 

[rokshana]

Yeah,


Yeah, I get that. So turn it around for you: I am 100% sure I'd be more confident in my PA/NPs managing a post-op surgical patient than an IM resident.

And I never said an NP or a PA is a physician. But some of the comments about them belie a lack a basic professional respect for their knowledge and role.

That’s is a bit apples and oranges, but actually for the comorbidites...htn dm, copd and the meds for these issues...again the IM resident is actually going to be the one doing the inevitable Medicine consult...just as there would be a surgery consult for the post op wound management.
everyone has their roles...

 

[rokshana]

Maybe not some of the interns... 😉

It’s march...they should by now!

 

[Dr.LeoSpaceman]

That’s is a bit apples and oranges, but actually for the comorbidites...htn dm, copd and the meds for these issues...again the IM resident is actually going to be the one doing the inevitable Medicine consult...just as there would be a surgery consult for the post op wound management.
everyone has their roles...

Point of order: There are no "inevitable medicine consults" on my services. I'll consult the PCP if they round at the hospital because it's collegial. But if the patient has stable chronic medical issues, I'm capable of managing them post-op and know when I need additional input (which is more likely to be a subspecialist).

But set aside that fact, and there plenty that goes into managing a post-op patient that's not related to the comorbidities. Especially when people start having complications. This is the area where the comparison is appropriate.

 

[NotAProgDirector]

But not more than an IM resident for anything complicated with glucose management...they are very good at achieving a1c goal and inpt blood sugar goals for the vast majority of dm2 pts because they are good with the algorithms and can have more frequent contact, but have a pt with cfrd, u 500 needs, or dm that is not type 1or2 and ,no,they will not have the critical thinking skills to manage those pt...they are not supposed to ... their training is nursing not doctoring and just because they are a DNP does not make them a physician,period .

We're going to have to agree to disagree. Broad statements like this are rarely completely accurate. The inpatient diabetic team I have is all NP driven. They are infinitely better at managing complex diabetics than I am. Starting U-500 is restricted -- I have to get their input to start it (we have had too many hypoglycemic catastrophies). Not all NP's are created the same. Ours have years of experience, managing the most complex diabetics we have.

 

[Raryn]

We're going to have to agree to disagree. Broad statements like this are rarely completely accurate. The inpatient diabetic team I have is all NP driven. They are infinitely better at managing complex diabetics than I am. Starting U-500 is restricted -- I have to get their input to start it (we have had too many hypoglycemic catastrophies). Not all NP's are created the same. Ours have years of experience, managing the most complex diabetics we have.

Of course, inpatient diabetes management is as much of an art as it is a science. Look at the all the various options for regimens for things like tube feeding, patients on steroids, patients on U500 at home, etc - you ask 10 board-certified endocrinologists to come up with a regimen in any of those cases and I *promise* you, there will be at least 3-4 different answers for each of them. Your NPs will probably come up with one of the reasonable options - but it probably won't overlap exactly with what @rokshana would do. Of course, neither would the regimen that I come up with.

In fact, I actually wouldn't be surprised if someone (yes, even an NP) who does nothing else but managing inpatient diabetes might actually have more general success at it than I would (I don't do any inpatient work at the moment). But I do agree that there may be more nuanced cases (she mentions cystic fibrosis related diabetes as an example) where their more limited training may be a handicap relative to someone with more general experience (i.e. a physician).

Regardless though, you (or any of your residents) are probably facile enough with insulin to manage the majority of patients with it without needing a consulting service. Just about any internist *should* be - the question ends up being do you have the time to do it?

 

[scarletgirl777]

I am a senior resident in a specialty. We have a midlevel who runs and bills for her own follow up clinic with no direct attending supervision. If my attending is in a meeting sometimes he will have me tell her about the case and she will take over the note and sign it. She would also go into the room and speak to the patient but yes it happens. This is rarely true of consults too but he will always at least meet those patients for a few minutes.

 

[scarletgirl777]

Sad, this whole post really. Is this what medicine has come to?

I never thought to be offended by it before this thread lol. I will say that for the consults she is not precepting per se as she does not know the specific details of the treatment plan for this patient, I am the one telling the patient. I see it as her helping with the documentation. And for the followups most of them I don't see as educational anyway at this point... I just see it as a billing hoop to get her on there.

 

[maxxor]

I never thought to be offended by it before this thread lol. I will say that for the consults she is not precepting per se as she does not know the specific details of the treatment plan for this patient, I am the one telling the patient. I see it as her helping with the documentation. And for the followups most of them I don't see as educational anyway at this point... I just see it as a billing hoop to get her on there.

That’s the ultimate problem. It shouldn’t be a billing hoop at all. If a mid level can bill, it doesn’t make sense that a senior residents in a specialty (maybe with a full license) cannot.

 

[jw3600]

Actually, this happens rarely in my program and it can be OK. If the NP has lots of experience in a specific field, for example. We have an inpatient diabetes consult team run by NP's -- they are amazing at dealing with complex insulin regimens, especially U-500 when it's needed. We also have an IV nutrition team in charge of all TPN run by an NP and pharmacist. Some subspecialty clinics have NP's that see the routine, non-operative cases -- Urology, for example, has NP's that see all the patients with lower urinary tract symptoms (men with BPH, women with incontinence and/or chronic cystitis). These can be great experiences for residents.

But the described situation isn't that.



I agree, sounds like a one time deal where someone made a dumb decision. I probably wouldn't have complained or done anything about it. The NP might have been super uncomfortable with the whole thing, but felt stuck too.

Beginning of the end folks.

 

[maxxor]

Beginning of the end folks.

Agree.

I so rarely see outpatient resident notes anymore at my mega academic medical center. All NP. Such a huge change from when I was a medical student in the same place.

 

[NotAProgDirector]

Beginning of the end folks.

really? At my shop, the NP's see the non-operative cases, and the residents get to spend more time in the OR.

Whether NP/PA's are good or bad for the medical system is an open question. But they can be very helpful in getting work done that residents used to do because "someone had to do it"

 

[IMreshopeful]

Point of order: There are no "inevitable medicine consults" on my services. I'll consult the PCP if they round at the hospital because it's collegial. But if the patient has stable chronic medical issues, I'm capable of managing them post-op and know when I need additional input (which is more likely to be a subspecialist).

But set aside that fact, and there plenty that goes into managing a post-op patient that's not related to the comorbidities. Especially when people start having complications. This is the area where the comparison is appropriate.

I’m at a large academic medical center where we got consulted all the time for nonsense for medical or cardiac issues (most of which are chronic) by the surgical teams. Your experience with managing these patients does not mean every surgeon is comfortable with routine post op medical management.

I don’t deny that a surgical PA or whatever MIGHT have more experience managing post op care. That being said frequently in my experience these guys get dumped on our medical service post whatever because they’re “too complicated medically to manage”. So my anecdote is about as valid as your anecdote.

 

[Dr.LeoSpaceman]

I’m at a large academic medical center where we got consulted all the time for nonsense for medical or cardiac issues (most of which are chronic) by the surgical teams. Your experience with managing these patients does not mean every surgeon is comfortable with routine post op medical management.

I don’t deny that a surgical PA or whatever MIGHT have more experience managing post op care. That being said frequently in my experience these guys get dumped on our medical service post whatever because they’re “too complicated medically to manage”. So my anecdote is about as valid as your anecdote.

Cool. As long as we agree my surgical PA is better at managing "surgical" to things: drains of any kind, g-tubes (it's leaking!), wound complications, etc.

 

[rokshana]

Cool. As long as we agree my surgical PA is better at managing "surgical" to things: drains of any kind, g-tubes (it's leaking!), wound complications, etc.

Sure but my resident is better at managing that same pts COPD,HTN, DM than your PA will ever be.

 

[Dr.LeoSpaceman]

Sure but my resident is better at managing that same pts COPD,HTN, DM than your PA will ever be.

Where did I argue otherwise? You'll recall my initial point is that some PAs/NPs possess specialized knowledge that exceeds that of residents in certain situations, even though they aren't physicians.

 

[IMreshopeful]

Cool. As long as we agree my surgical PA is better at managing "surgical" to things: drains of any kind, g-tubes (it's leaking!), wound complications, etc.

We actually do get some exposure managing drains and wounds in cardiology with devices and device extractions (last weekend I was on call I had to pull a drain post extraction for the EP service...) as well as pericardiocentesis drains. It’s not like I have ZERO experience with this. But yes your PA probably does have more experience with the intraabdominal stuff.

Regardless... you’re still talking about a very specific skill that is being performed under your domain. I’m assuming you still make decisions about pulling drains and such.

 

[Gastrapathy]

It’s not a question of what they see, it’s question of how they think. If you don’t have a physician who can teach it as well as the NP, you really can’t know whether what they are saying is right.