Policy of the Graduate Medical Education Committee
Section:  Educational Administration 
Subject:  Guidelines for Maintaining Educational Records
Number:  1.101
Date Developed: 6/2007
Date Review/Revision: 8/10 
ACGME Institutional Requirement Source: ACGME e-Bulletin (February 2005, August 2008)

Purpose
To provide guidelines for Program Directors and Program Coordinators with regards to maintaining the educational records of residents/fellows.

Policy
There are two types of records maintained for residents/fellows who are currently in or have completed ACGME-accredited residency/fellowship training programs sponsored by the College of Medicine.

 1.   Dean’s Office Personnel File: the Assistant Dean for Housestaff Affairs (ADHA) maintains a file on each resident/fellow which includes:
·        biographical data sheet,
·        VISA information and ECFMG certification,
·        signed letter of appointment (contract)
·        other employment information. 

When the resident/fellow graduates or leaves the program, this record is converted to a electronic record.  The ADHA maintains a record of training dates for each resident/fellow, which are to verify information requested by licensing bodies or hospitals and the home address and/or business address after the resident leaves UAMS.  The ADHA verifies only the dates the trainee was in a program in the COM, but does not verify successful completion or credit for training.  Information about successful completion or credit for training is maintained by the training program director.

2.                  Department File: the training program director maintains the permanent educational record for each resident/fellow.  The educational record should include, but is not limited to, the bulleted items below. The first three items described below should be kept for a minimum of 7 years after the resident has graduated.

·        documents considered directly related to the academic and professional development of the resident; examples include in-service examinations, surgical procedure/log books, results of skills tests, results of assessments of the general competencies permission to moonlight.  

·        documents about medical conditions - should be kept separate from the resident’s educational or personnel file. 

·        optional documentation - documentation primarily to assist the program director in remembering the facts can be placed in a separate file maintained by the program director.

·       interview materials – should be kept 3 years a the outside, 1 year at least.

The following core files should be kept indefinitely by the department, to accommodate requests for primary source verification for residents who have completed the program:

·       written evaluations by faculty and others -  these may be monthly, quarterly, rotational, every six months, annually, end of training.  Such evaluations stipulate the degree to which the resident/fellow has mastered each component of clinical competence and skills identified in the program's curriculum. These should be reviewed periodically with the resident/fellow, and the resident/fellow should acknowledge (usually by signature) that the review has been provided. 

 ·       program director's final written evaluation for each resident/fellow who completes the program. This evaluation must include a review of the resident/fellow's performance during the final period of training and should verify that the resident/fellow has demonstrated sufficient professional ability to practice competently and independently and should verify successful completion or credit for training. This final evaluation should be part of the resident/fellow's permanent record maintained by the program director.

·       documentation of disciplinary or remediation actions - when a training program director counsels a resident/fellow about a particular academic or behavioral issue, the training program director should record the discussion in written format.   Documentation that reflects the legitimate professional development and skills of the resident/fellow should remain a part of the permanent record.  However, if a resident/fellow had one episode of difficulty and then improved to the expected level, the program director would have the discretion to remove this documentation from the permanent file. Training program directors may seek advice from legal counsel about documents and records in cases of disciplinary actions. Documents about formal grievance proceedings should be kept separate from the resident’s educational file.

For residents who do not complete the program or who are not recommended for Board certification, most programs will keep the entire file indefinitely in case of a subsequent legal action.

 Residents/fellows must have access to their educational record and can review their record (while being observed). Upon written request by the resident/fellow, a copy of all contents of their record must be provided to them.  All patient identification included in these records should be redacted.