EXCEPTION CLINIC
                        SAMPLE TEMPLATE
                                
       I have reviewed with the resident (patient's name)
                                                          medical history,
physical examination, diagnosis, and results of tests and
treatments and agree with the patient's care as
documented above.


                       USE "-GE" MODIFIER


                                                                  
         Date   Dr. Teaching Physician 









     


                            SURGERY
                        SAMPLE TEMPLATE
                                
     I was present during (or personally performed) the key
portions of the procedure, which included                           
                                                                                            
    as well as other aspects of the case. I was immediately
available during the entire procedure except for                  
                                                                                             
during which time Dr.                                  was available.
                                
                                
                       USE "-GC" MODIFIER
                                
                                
                                                              
   Date                        Dr. Teaching Physician






     


                           ANESTHESIA
                        SAMPLE TEMPLATE
                                
                                
     I was present during (or personally performed) the key
portions of the procedure, which included                           
                                                                                            
    As well as other aspects of the case.  I was immediately
available during the entire procedure except for                  
                                                                                             
during which time Dr.                                  was available.

     
                       USE "-GC" MODIFIER
                                
                                
                                                               
        Date  Dr. Teaching Physician





     


                        SAMPLE TEMPLATE
                                
                                
      Resident's history reviewed, patient interviewed and
examined.  Briefly, history is as follows                              
                                                                                           .
On exam, I find (list what you did and findings)                  
                                                                                          .
Of note is                                                                              
                         .  The evaluation and treatment plan was
reviewed with the resident. Labs/test show                          
                                                                                 , and I
confirm/revise the diagnosis is                                           .
Care Plan:                                                                           .
See resident's note for further details.
     
                       USE "-GC" MODIFIER
                                
                                
                                                                       
     Date     Dr. Teaching Physician