Trainee Accountabilities

Prescriber trainees, including medical students, residents and fellows, are supervised by fully licensed prescribers. These "supervising" prescribers may co-sign or attest to trainee activities, and are synonymous with "authorizing providers" for such purposes:

  • Medical student orders and documentation are signed by a resident or a supervising prescriber.

  • Residents sign their own orders but some documentation (e.g., consult, discharge summary) is co-signed by a supervising prescriber.

  • Key Concept: Provider - Physician - Prescriber

Authorizing prescribers are automatically assigned for inpatient (= attending prescriber), emergency (= attending prescriber) and outpatient (= encounter prescriber) trainee roles and contexts. However, there are some situations where the default assignments need to be manually overridden.

Trainee Roles

All trainees select a "job" (e.g., "Resident Physician", "Resident Surgery") and a "context" department (e.g., "EDMONTON ZONE CARDIOLOGY", "EDM UAH KEC GENERAL SURGERY") when logging in to Connect Care. These choices affect how Hyperspace is set up, as well as which clinical information system (CIS) modules are available to the trainee. Trainees can change both job and context easily from within a Connect Care session:

Multiple Supervisors

In some contexts, multiple providers relate to the work of a single trainee working in a single Connect Care session. To avoid ambiguity, a requirement for "Supervising Provider" selection at login was introduced for Connect Care trainees in second quarter 2020. This requirement was later removed because of practical difficulties with some workflows. Instead, the CIS assigns a default authorizing prescriber based upon the panel of providers linked to an individual patient for a specific healthcare encounter. This works most of the time; however, there are situations when this information may not suit the trainee's clinical task.

In order for critical, ambulatory and late-reporting inpatient results to route to the right In Basket and co-sign prompts to go to the right supervisor, it is important for trainees to understand Connect Care's default authorizing prescriber and when this should be manually overridden.

Default Authorizing Prescriber

A trainee is assumed to be supervised by another provider according to a hierarchy of possibilities. If first choice is not known, then the second option is used. The default authorizing provider differs by context, using provider associations specific to the patient and encounter:

  • Emergency Departments (EDs)

    1. Attending provider for the patient ED visit

    2. Current provider (trainee themselves, IF they are an authorizing provider)

  • Inpatient Departments

    1. Attending provider for the patient admission

    2. Current provider (trainee themselves, IF they are an authorizing provider)

  • Outpatient Departments

    1. Encounter provider for the patient visit

    2. Current provider (trainee themselves, IF they are an authorizing provider)

If the first option is not available (e.g., currently unassigned) and the second option is not appropriate (e.g., trainee not able to be an authorizing provider), then the trainee is prompted to select an authorizing provider at the time of ordering.

Authorizing Prescriber Override

The default assignment of an authorizing provider will work most of the time. However, it is important to know how to select an alternate authorizing provider if the default does not fit a specific patient interaction.

Emergency Department Supervising Prescribers

Trainees assigned to ED rotations may work with more than one attending prescriber during a given shift. This is handled by the trainee “signing in” to the Emergency Department (ASAP) track board and selecting a “supervisor”. This selection can be changed at any time.

Additional Prescriber Copies

Sometimes it is important to bring particular test (“procedure”) results to the attention of prescribers other than the ordering or authorizing prescriber. This is easy to do at the time of ordering by using the “CC Results” field found within procedure orders. One can select one or more "copy-to" providers.

Trainee Multi-Supervisor Scenarios

Trainees who find themselves in multi-supervisor contexts can review how the supervisor hierarchy may apply:

Trainees Serving Consult Services

Trainees who help respond to emergency department (ED) or inpatient (IP) consultation requests must pay particular attention to orders placed on behalf of the consulting service. These workflows bear the greatest risk for ordered test results not routing to an accountable consultant, especially when the trainee is on-call or covering more than one consulting specialty.

When trainees (medical students, residents, fellows) help with ED or IP consults, they are acting on behalf of an Authorizing Prescriber. Typically, the Authorizing Prescriber is the Attending Physician responsible for the consulting service at the time the consult is fulfilled. Timing matters because responsible consultants can change day-to-day, with possibly different consultant(s) responsible during night or weekend on-call periods.

Given that trainee assignments and schedules are not managed in Connect Care, the CIS has no awareness of the service or attending that a consulting trainee may act on behalf of when placing orders. This is of less consequence for routine tests that are rapidly resulted while the patient is in the ED or hospital, as such results are reviewed in the chart and are not routinely routed to In Baskets. Lack of clarity about trainee accountability, however, is of great consequence when investigation (e.g., imaging studies, labs) are reported or resulted after the patient leaves the ED or hospital. If the consulting service ordered the late-resulting investigation, then it is essential that the result notification be routed to the correct Authorizing Prescriber In Basket.

Emergency Department Consults

Consulting trainees must identify the Authorizing Prescriber they are working with when ordering tests on non-admitted ED patients. This will ensure that the test results route to the appropriate consultant for follow-up, in compliance with the College of Physicians and Surgeons of Alberta Code of Conduct.

Trainees should explicitly associate a consulting authorizing provider with a test or imaging order by overriding the default authorizing provider assigned by Connect Care. This is done for one or more orders by selecting "Providers" from the ordering panel "Options" menu, then entering the consultant prescriber in the "Authorizing Providers for procedures" field.

Omitting this step leaves the Attending Emergency Physician responsible and liable for the consultant-ordered test. They may be unaware of the tests being ordered, may not appreciate the question the test is meant to answer and may not have the means to follow-up with the patient.

Inpatient Consults

Consulting trainees must also take care to identify a non-default Authorizing Prescriber when ordering tests on inpatients where the result may report after patient discharge or where the result is part of the consulting service's follow-up plans or accountability.

When suggested tests or other procedures directly relate to consulting services, trainees should explicitly associate a responsible consulting authorizing provider by overriding the default assigned by Connect Care. This is done the same way as described for consultant orders placed for non-admitted ED patients.