In a Teaching Hospital setting, what documentation needs to be indicated in the medical record for an assistant surgeon when a qualified resident is not available?
In AMC (Academic Medical Centers), there are times when a surgical procedure is so complex that it requires multiple surgeons. Generally the expectation is that a resident(s) would be used to assist with the surgery. If no resident(s) are available, the resident(s) available are not sufficiently qualified to provide the needed assistance or the attending physician never uses residents then an attending can be used to assist with the surgery. When billing for such assistant surgeon services, one of the following must be documented in the medical record: