Resident and Fellow Policy Manual

Appendix 1 - Policy on Resident Supervision:

The following policy on resident supervision has been developed to conform to the New York State Health Code and Section MS.6.9/MS.6.9.1 of the Standards of the Joint Commission on Accreditation of Healthcare Organizations.

All residents must be supervised by a member of the Medical Staff or qualified attending physician.  The attending physician must be in the hospital, or he/she must be immediately available by telephone and readily available in person (within 20-30 minutes) at all times.

All residents will consult with the attending physician regarding the assessment and treatment of a patient’s illness.  Treatment plans will be in accordance with the attending physician’s recommendations.

When attending physicians are immediately available by telephone and readily available in person when needed, the onsite supervision of routine hospital care and procedures in the acute care specialties of anesthesiology, family practice, medicine, obstetrics, pediatrics, psychiatry and surgery may be carried out by postgraduate trainees who are in their final year of training, or who have completed at least three years of training in their program.

For non-acute care specialties, onsite supervision of routine hospital care and procedures may be performed by a resident who is not in the final year of training if the department has specifically credentialed that individual resident to work in that capacity and supervise other residents.  The department must maintain written documentation of such credentialing for each resident who assumes such responsibility.

Attending physician supervision in surgery must be direct personal supervision of all surgical procedures requiring general anesthesia or an operating room procedure.

All supervision must be documented in the resident rotation schedules and by attending physician on-call schedules.  Each department will have available at all times such schedules and will provide such to all interested parties.

Each training program may have additional supervision standards as dictated by their Residency Review Committees (ACGME) which may be more restrictive than these outlined above.  If so, the more restrictive standards will be followed.

See also Policy on Order Writing Credentialing and Procedure Credentialing

Approved by GMEC 3/1/99

Updated by Associate Dean for GME 3/1/02