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From Ashley Kliewer, MS, PA-C, FHM, LGHP Hospitalists Lead Advanced Practice Provider, PSPA Region Affairs Committee Co-Chair
With support from the Hospital and Health System Association of Pennsylvania and physician organizations, on Jan. 26, 2013, House Bills 1348/Act 100 and 1351/Act 101 went into effect, amending the medical practice acts to allow flexibility related to physician countersignature of physician assistant patient records.
Under the new state regulation, 100 percent countersignature within 10 days is required for:

  • The first 12 months of the physician assistant’s practice post-graduation and after obtaining licensure

  • The first 12 months of the physician assistant’s practice in a new specialty

  • The first 6 months in the same specialty under a new primary supervisor, unless the new primary supervisor was registered as a substitute supervisor for at least 6 months under another written agreement

After the required timeframe for countersignature is fulfilled, the supervising physician may choose to deviate from 100 percent chart review. The supervising physician must complete and submit a written agreement change form -- including details of what charts and how often the patient record will be reviewed -- for approval by the State Board of Medicine or State Board of Osteopathic Medicine. 1
After this regulatory change went into effect in fall 2014, the Department of Health acknowledged that since hospital licensure regulations reference the scope of practice in the Medical Practice Act and the Osteopathic Medical Practice Act, the countersignature state regulation changes were incorporated by reference into hospital regulations, permitting physician assistants to write orders and record reports and progress notes in medical records as established by the Medical Staff. During the same year at LGH, the Medical Staff bylaws were revised for physician assistants, allowing for less than 100 percent countersignature after fulfilling the state requirement.
In 2015, with the help of the LGH Medical Staff and the Pennsylvania Society of Physician Assistants, the physician assistant rules and regulations and job description were revised and approved by the Medical Executive Committee and Board of Trustees to include proper language reflecting the state regulatory changes allowing for less than 100 percent countersignature. History and physicals, consult notes, admit orders, respiratory DME order, home health certification, progress notes on a patient transferred to a higher level of care, and new or modified discharge medications continue to require countersignature from the supervising physician.
Currently, any supervising physician and physician assistant team may submit a written agreement change form to the Board, which can be found on the State Board of Medicine and State Board of Osteopathic Medicine websites. Once approval is received from the Board, the supervising physician and physician assistant’s practice manager may notify the Medical Staff of the written agreement change approval, and the Medical Staff Office will place a ticket into EPIC. EPIC has created a template for physician assistants requiring less than 100 percent countersignature, mirroring our nurse practitioner colleagues.
As an example, LGHP Hospitalists already have implemented written agreement changes approved by the State Board of Medicine. In addition to countersignature requirements set forth in the bylaws, the LGHP Hospitalists physician assistants have a maintenance review of 45 charts per quarter.
Physician assistants are designed and trained to work closely with supervising physicians. The result of these countersignature changes enhances the physician and physician assistant team by improving efficiency without compromising the delivery of high-quality patient care at Lancaster General Health.
Helpful websites to assist with updating written agreement changes
Pennsylvania Society of Physician Assistants
State Board of Medicine Written Agreement Change form
State Board of Osteopathic Medicine Written Agreement Change form
1Hospital and HealthSystem Association of Pennsylvania PA Countersignature of Physician Assistant Patient Records Implementation of Acts 100 and 101 of 2013 in the Hospital Setting; “Use of Physician Assistants, Certified Registered Nurse Practitioners, Certified Nurse Midwives, Certified Registered Nurse Anesthetists, and Clinical Nurse Specialists in the Hospital Setting in Pennsylvania.

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