1. EACH USER WILL HAVE A UNIQUE LOGIN AND PASSWORD TO ACCESS ONLY THEIR PROGRAM INFORMATION 1

2. ONCE THE USER IS LOGGED IN, A MENU OF OPTIONS APPEARS ON THE LEFT HAND SIDE OF THE SCREEN. 2

3. ONCE THE ‘REPORTS’ OPTION IS SELECTED, TWO OPTIONS ARE AVAILABLE: 3

4. THE REPORT CAN BE RUN BY ADMIN YEAR AND TEST DATES. 4

5. ONCE THE REPORT HAS BEEN RUN, IT CAN BE EXPORTED INTO PDF FORM FOR EASIER VIEWING. IT CAN ALSO BE EXPORTED INTO OTHER FORMATS. 5

6. THE REPORT THEN OPENS IN A PDF FILE SO IT CAN BE PRINTED, SAVED, ETC. 6

7. USERS WILL ALSO BE ABLE TO PRODUCE SCORE REPORTS FOR THEIR PROGRAM. THIS REPORT CAN BE RUN FOR ONE SINGLE CANDIDATE OR AN ENTIRE CLASS. 7

8. ONCE THE USER SELECTS ‘CLICK’, A PDF COPY OF A SCORE REPORT IS GENERATED 8

9. RESIDENTS – SCOPE OF PRACTICE GUIDELINES FOR PROGRAM DIRECTORS AND TEACHING PHYSICIANS Michelle Gittler, M.D.

10. WHAT DO PROGRAM DIRECTORS AND TEACHING PHYSICIANS NEED TO KNOW?  Rules on Supervision of Residents Can be Found in Several Places:  ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION (“ACGME”) RULES – CORE STANDARDS  ACGME RULES FOR PM&R PROGRAMS  GUIDELINES DEVELOPED BY EACH TRAINING PROGRAM  MEDICARE TEACHING PHYSICIAN RULES FOR PAYMENT PURPOSES 10

11. RESIDENTS: LEVELS OF SUPERVISION  It is up to each program to determine what level of supervision is required based on three ACGME Levels of Supervision:  Direct supervision: the supervising physician is physically present with the resident and the patient  Indirect Supervision: Two Types  With direct supervision immediately available: the supervising physician is physically within the hospital (or other care site) and is immediately available to provide Direct Supervision 11

12. ACGME LEVELS OF SUPERVISION (CONT.)  With direct supervision available: the supervising physician is not physically present within the hospital or other site of patient care but is immediately available by means of telephone and/or electronic modalities, and is available to provide Direct Supervision 12

13. ACGME REQUIREMENTS  ACGME common program requirements:  The program must demonstrate that the appropriate level of supervision is in place;  Clinical responsibilities must be based on PGY-level (Program Year-Level), patient safety, resident education, severity and complexity of condition  PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. This means the supervising physician is physically within the hospital and immediately available to provide direct (i.e. in person) supervision, OR Is physically in the hospital and immediately available 13

14. RESPONSIBILITY OF RESIDENCY PROGRAM  Each Program must define what residents can do with and without direct supervision.  For example, a program could decide that a PGY-2 must have direct supervision when performing trigger point injections or other large joint injections but that a PGY-3 could perform those procedures with direct supervision immediately available. 14

15. SUPERVISION AS IT APPLIES TO PM&R PROCEDURES PERFORMED BY RESIDENTS  Types of services that Programs might allow residents to perform without direct supervision  Histories and physicals  Preparing notes and documentation  Prescribing or certifying prescriptions or orthotics and prosthetics/DME/home health  Prescription of physical, occupational and speech therapy 15

16. SUPERVISION AS IT APPLIES TO PM&R PROCEDURES PERFORMED BY RESIDENTS  Types of services that might require direct supervision, depending on experience of resident:  Performing trigger point injections  Performing botox injections  Performing intra-articular large joint injections with or without ultrasound guidance  Performing an electrodiagnostic study  For example, PGY-2s might have to perform these services under direct supervision where Program might allow PGY-3s to perform without direct supervision or with direct supervision immediately available. 16

17. MEDICARE TEACHING PHYSICIAN RULES SERVE AS FURTHER GUIDANCE  These rules govern when and under what conditions a resident’s service can be billed to Medicare.  Many private payers adopt Medicare policies as their own.  Teaching physician can bill Medicare for the services of a resident only if:  The teaching physician either personally performs or was physically present during the critical or key portions of the service  The teaching physician documents his or her participation in the management of the patient 17

18. MEDICARE TEACHING PHYSICIAN RULES  If the teaching physician rules are not met, residents’ services cannot be billed and are considered paid through the hospitals’ graduate medical education (GME) payments.  If the teaching physician does not bill Medicare, then physical presence is not necessarily required.  Refer to ACGME and Program rules on supervision 18

19. WHAT ABOUT STATE LICENSURE?  Medical licensure laws in most states require residents to be licensed by the state or have a special training license which allows them to practice only in the hospital and under supervision.  State licensure laws vary with respect to when during training a resident can obtain full licensure.  Some states allow after 1 year of ACGME training; others after 2 years  Rules may differ for foreign medical graduates. 19

20. STATE SCOPE OF PRACTICE LAWS  Scope of practice for residents is generally based on type of licensure.  Once fully licensed, states generally pose no restrictions on residents’ scope of practice.  Some states grant restricted licenses for those in early stages of training. These licenses allow practice in the hospital under supervision.  However, it is important to check laws in your specific state. 20

21. LIABILITY ISSUES  Educational institution must provide residents with liability coverage during their training (ACGME requirement).  Coverage would extend to services provided outside of the hospital provided it is part of the residents’ approved ACGME training program. 21

22. STANDARD OF CARE FOR RESIDENTS  Courts have generally avoided involvement in setting the scope of practice for residents.  In professional liability cases, residents are generally held to the same standard of care as physicians.  Illustrative Court cases:  Centman v. Cobb (Indiana Ct. App. 1991):“ first-year residents are medical practitioners who must exercise the same standard of skill as a physician with an unlimited license to practice medicine.”  However, in Phelps v. Physicians Ins. Co. of Wisc. (Wisc., 2005) the court held that a first year unlicensed resident was not held to the standard of care of a licensed physician but was still found liable for acting outside of his scope of authority or expertise.  But hospital and educational institutions also have a legal duty to supervise care provided by residents.(Felice v. Valley Lab; La. Ct. App. 1988) 22