The Role of Chart Co-Signature in Physician Supervision of Physician Assistants:
What is Best for Patient Care?

THE PHYSICIAN ASSISTANT PROFESSION'S COMMITMENT TO PHYSICIAN-DIRECTED PRACTICE

The physician assistant (PA) profession was created in the late 1960s by physicians who envisioned a medical professional, trained in the medical model, who would work closely with a physician or group of physicians to enhance the doctor's ability to efficiently and effectively provide patient care. The landscape of health care has undergone many changes since then. However, the PA profession has remained true to the vision of its physician founders. Physician assistants embrace physician supervision and do not seek independent practice.

The relationship between PAs and physicians begins in PA educational programs where physicians, PAs, and others provide instruction in a curriculum following the medical school model. PA students typically share classes, facilities, and clinical rotations with medical students. PA programs are usually 25-27 months in length.1 Program applicants must complete at least two years of college courses in basic science and behavioral science as prerequisites to PA training. PA programs begin with a year of basic medical science courses (anatomy, pathophysiology, pharmacology, physical diagnosis, etc.). Following the basic science and medical science classroom work, PA students enter the clinical phase of training. This includes classroom instruction and clinical rotations in medical and surgical specialties (family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry). PA students complete on average 2,000 hours of supervised clinical practice prior to graduation.

Because they train using similar curricula, training sites, faculties and facilities, physicians and PAs develop a similarity in medical reasoning during their schooling that eventually leads to homogeneity of thought in the clinical workplace. 2

Physician assistants are committed to practicing as members of physician-directed teams. The definition of the profession, as stated in AAPA policy, demonstrates this commitment:

"Physician assistants practice medicine with supervision of licensed physicians." 3

This commitment to supervision by physicians is also evident in all state laws governing physician-PA practice. Although there is some variety in the way in which the requirement is stated, all state laws require a supervising physician to be available either in person or via telecommunication to consult with the PA at all times that the physician assistant is seeing patients. 4

 

THE EVOLUTION OF CHART CO-SIGNATURE REQUIREMENTS IN STATE LAWS AND REGULATIONS

The earliest state laws for PAs commonly required physician co-signature of all charts or orders. More recent revisions, however, have adapted these provisions. Some states require a small fraction of charts to be co-signed, while a sizeable number of states have no requirement for chart co-signature by physicians in law or rule.

 

PHYSICIAN OVERSIGHT OF PA PRACTICE - THE ROLE OF CHART CO-SIGNATURE

As physicians and institutions seek to increase efficacy and efficiency in medical practice, and as technology changes the way in which care is delivered, many aspects of medical systems are being critically evaluated. Among these is the role of physician co-signature of chart entries and orders written by physician assistants.

There are times when chart co-signature by physicians is appropriate. PAs have a responsibility to ensure that a supervising physician reviews complex problems and that the review is documented. Supervising physicians should review PA-written chart entries, either every one or selected records, if that is the physician's preference. Licensed health care facilities, institutions, and group practices are obligated to put in place those requirements that best suit the needs of the patients served by each individual organization. Facilities and groups may decide that a targeted co-signature requirement is consistent with their mission.

The American Medical Association has recognized the individual physician's role in determining specific aspects of PA practice and oversight. In 1995, the AMA House of Delegates adopted Guidelines for Physician/Physician Assistant Practice. As noted in the Guidelines, review of PA practice is the responsibility of the physician and PA:

 

Guidelines for Physician/Physician Assistant Practice

1. The physician is responsible for managing the health care of patients in all practice settings.

2. Health care services delivered by physicians and Physician Assistants must be within the scope of each practitioner's authorized practice as defined by state law.

3. The physician is ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of the Physician Assistant, ensuring the quality of health care provided to patients.

4. The physician is responsible for the supervision of the Physician Assistant in all settings.

5. The role of the Physician Assistant(s) in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the Physician Assistant and based on the physician's delegatory style.

6. The physician must be available for consultation with the Physician Assistant at all times either in person or through telecommunication systems or other means.

7. The extent of the involvement by the Physician Assistant in the assessment and implementation of treatment will depend on the complexity and acuity of the patient's condition and the training and experience and preparation of the Physician Assistant as adjudged by the physician.

8. Patients should be made clearly aware at all times whether they are being cared for by a physician or a Physician Assistant.

9. The physician and Physician Assistant together should review all delegated patient services on a regular basis, as well as the mutually agreed upon guidelines for practice.

10. The physician is responsible for clarifying and familiarizing the Physician Assistant with his supervising methods and style of delegating patient care.5

The Joint Commission on Accreditation of Healthcare Organizations recommends that each accredited organization determine the necessity for co-signature. The relevant standard states:

"The medical staff rules and regulations or policies define what entries, if any, by house staff or nonphysicians must be countersigned by supervising physicians."6

The American Academy of Physician Assistants views physician oversight to be the joint responsibility of the physician and the PA. According to the AAPA's Model State Legislation for Physician Assistants:

"It is the obligation of each team of physician(s) and physician assistant(s) to ensure that the physician assistant's scope of practice is identified; that delegation of medical tasks is appropriate to the physician assistant's level of competence; that the relationship of, and access to, the supervising physician is defined; and that a process for evaluation of the physician assistant's performance is established." 7

 

PHYSICIAN CO-SIGNATURE OF PA-WRITTEN CHART ENTRIES - WHAT IS BEST FOR PATIENTS?

Early physician assistant statutes were written without the benefit of experience with PA practice. American health care now has nearly 40 years of experience with physician-PA teams. The early state laws requiring all PA-written chart entries to be signed by physicians were drafted to assure ongoing physician oversight. But like many aspects of clinical medicine, the best patient care decisions are made not as blanket requirements in law, but rather as a customized response to individual practice situations.

Rigid co-signature requirements in state law can actually diminish the opportunity for quality physician oversight. If, for example, a physician is required to counter-sign all routine orders, the doctor has less time available for in-depth discussion of specific cases with the physician assistant, or for review of practice guidelines or systems for care.

The ideal system for physician oversight is designed at the practice or the facility in a way that maximizes excellent care for patients. If a physician is supervising a PA who is new to the practice, the doctor may decide to countersign, for a period of time, certain types of orders before they are implemented. If a physician-PA team has worked together for many years, a monthly case conference, with teaching cases selected both by the PA and the physician, may be the most quality-focused oversight system.

Laws and regulations governing physician-PA teams should be updated periodically to reflect experience with PA practice and evolutions in health care systems. While preservation of supervisory and oversight function is critical, requiring supervising physicians to co-sign every PA-written order or chart removes the doctors' discretion to exercise supervision in the way that works best for their practices. It can also place an unnecessary burden on the doctor, detracting from the efficiency of care the physician-PA team delivers.

 

CHART CO-SIGNATURE UNDER ELECTRONIC MEDICAL RECORDS SYSTEMS

Electronic medical records are increasingly taking the place of the traditional paper chart. AAPA supports the establishment of a patient-centered health care system in which there is an efficient and continuous exchange of information among health care professionals,8 and such systems often include the use of electronic medical records. In those instances where state law, facility guidelines, or physician preference call for chart co-signature, physicians should be able to meet the co-signature requirement with notations in the electronic medical record. Thus, facilities or practices that require physician co-signature should take care to invest in electronic medical records systems that allow physicians to co-sign records quickly and conveniently.

 

REFERENCES


  1. Twenty-First Annual Report on Physician Assistant Educational Programs in the United States, 2004-05. Alexandria, VA. Association of Physician Assistant Programs.
  2. White GL, et al. Physician assistants and Mississippi. J Miss St Med Assn, 1994;25:353.
  3. American Academy of Physician Assistants 2005-2006 Policy Manual. Alexandria, VA.
  4. Physician Assistants: State Laws and Regulations, Tenth Edition. Alexandria, VA. American Academy of Physician Assistants, 2006.
  5. American Medical Association. Guidelines for Physician/Physician Assistant Practice. Policies of the AMA House of Delegates H.160-947. Chicago , IL . .
  6. Comprehensive Accreditation Manual for Hospitals. Joint Commission on Accreditation of Healthcare Organizations, 2002. Oakbrook Terrace, IL.
  7. Model State Legislation for Physician Assistants, American Academy of Physician Assistants, 2002. Alexandria, VA.
  8. American Academy of Physician Assistants 2005-2006 Policy Manual. Alexandria , VA.

 

Issue Brief: The Role of Chart Co-Signature in Physician Supervision of Physician Assistants: What is Best for Patient Care?

 

 

Last Revised: 8/29/06