Policy of the Graduate Medical Education Committee
Section: Resident Support/Conditions for Appointment
Subject: Medical Records
Number: 2.800
Date Developed: 2/00
Last Review/Revision: 10/05
Replaces:  Policy of same name dated 3/02
ACGME Requirements: Institutional II.F.2.c

Purpose
To establish the work environment as it relates to medical records and the responsibilities of the resident for the completion of medical records in the major participating institutions.

Definitions
Major Participating Institutions: For the purposes of this policy this includes: Arkansas Children's Hospital (ACH), UAMS Medical Center (University Hospital, UH), Central Arkansas Veterans Health Care System (CAVHS).

Medical Record: The basic tool for planning patient care and for communication between physicians and other persons contributing to patient care. It reflects the quality of patient care that is provided and documents the course of each patient's illness and care.

Policy
1. Medical Records System
The medical records system shall support the education of residents, quality assurance activities and provide a resource for scholarly activity.  Medical records must be available to residents at all times. Each participating institution shall orient residents to the medical records system to include the policies and rules and regulations regarding the delinquent medical record procedure.

2. Resident Medical Records Agreement
Upon entering the residency (includes fellowships) program each resident shall sign a medical records agreement which applies for the duration of the program.  The agreement is returned to the Director of Housestaff Records prior to beginning the program.  By signing the agreement, the resident commits to:

·        Follow the rules and regulations regarding medical records while on service at ACH, UH or CAVHS. 

·        Date, time and complete all orders and progress notes at the time they are written.

·        Complete a written history and physical on each patient within twelve (12) hours of admission.

·        Write a progress note on each inpatient patient once every twenty-four (24) hours.

·        Sign verbal orders within twenty-four (24) hours after their occurrence. 

·        Complete and sign the Medical Records Face (Code) Sheet prior to the patient's discharge at VAH or complete the Discharge Summary Sheet without abbreviations prior to the patient's discharge at ACH.

·        Dictate operative reports immediately following surgery, if assigned.

·        Dictate discharge summaries prior to discharge or at the time of discharge or death of the patient, but no later than fourteen (14) days following the discharge or death.

·        Not remove the medical record from the approved locations without notifying the medical records department (UH, ACH) or signing out electronically (VAH).

·        Not copy the medical record without prior approval.

·        Dispose of all working documents printed from the electronic medical record in designated containers.

·        Become familiars with the rules and regulations regarding medical records while on service at ACH, UH, or VAH.   

·        Understand that the consequences of not completing delinquent records are possible sanctions, including suspension without pay and dismissal..

·        Comply with all Medicaid, Medicare and other federal program documentation rules.

·        Comply with HIPAA regulations

3. Delinquent Records
Operative Reports:
The operative report is considered delinquent if it is not completed within 24 hours.  All physicians involved in the operative case may lose their operating room privileges until the operative report is complete.

Medical Records:
Medical records shall be completed within 30 days following discharge to include the signature of the attending physician on the discharge summary.  Medical records not completed within 30 days are considered delinquent.  A resident shall not be held accountable for medical records that are not available at the time he/she presents to the Medical Records Department to complete the records.

4. Consequences of Delinquent Medical Records
Residency/Fellowship Program:
Individual programs may have consequences for residents who have delinquent medical records in addition to those specified by the institutions' rules and regulations.  If so, each Program Director shall provide written guidelines about a resident's failure to complete delinquent medical records.  These consequences may include, but are not limited to, the following:

·         Deductions from educational funds

·         Monetary fines

·         Probation

·         Suspension without pay

·         Dismissal

·         Withholding of training program certification

·         Loss of various privileges of the training program

Institution:
Residents may be suspended without pay for failure to complete delinquent medical records.  Suspension without pay will be according to the following procedure:

1. Upon notification of delinquent records, the Program Director will inform the resident in writing of the patient records, timeframe (e.g. one or two weeks) for completion, and the effective date of suspension without pay if the records are not completed. 

2. If the resident fails to complete the records by the deadline, the resident may be placed on suspension without pay according to the GMEC policy on Disciplinary Actions Including Probation, Suspension, and Dismissal.  The Program Director must notify the Director of Housestaff Records of the date of suspension without pay.