General Documentation Guidelines for Teaching Physicians and Residents
Both residents and teaching physicians may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity and may be:
• Dictated and transcribed;
• Typed;
• Hand-written; or
• Computer-generated.
A macro is a command in a computer or dictation application in an electronic medical record that automatically generates predetermined text that is not edited by the user. The teaching physician may use a macro as the required personal documentation if he or she personally adds it in a secured or password protected system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. If both the resident and the teaching physician use only macros, this is considered insufficient documentation.
