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: 2/09
Replaces:  Policy of same name dated 3/02
ACGME Requirements: Institutional II.F.2.c

Purpose
To establish the framework for the educational environment as it relates to medical records and the responsibilities of the resident/fellow for the completion of medical records.

Definitions
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 and documents the course of each patient's illness and care.

Medical Records System: A medical records system that documents the course of each patient’s illness and care must be available at all times and must be adequate to support quality patient care, resident/fellows’ education, quality assurance activities, and provide a resource for scholarly activity.

Deficient Medical Record: an incomplete medical record. 

Policy

1.         Each participating institution shall orient resident/fellows to the medical records system to include the policies and rules and regulations regarding the deficient and delinquent medical record procedure.

 2.         Resident/fellow Medical Records Agreement 

Upon entering a College of Medicine ACGME accredited program, each resident/fellow 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 Medical Records Agreement, the resident/fellow acknowledges:

·       The resident/fellow will complete all medical records according to the rules and regulations of the participating hospitals. 

·       The resident/fellow must comply with Medicaid, Medicare, and other federal program documentation rules.

·       The resident/fellow will comply with HIPAA regulations.

·       The failure to complete delinquent records may result in permanent documentation in the resident/fellow’s personnel file regarding lack of professionalism.  Further, continuing failure to complete delinquent records may result in further discipline, including suspension and/or dismissal from the program.  This type of documentation likely will result in difficulty in obtaining license, board certification and/or credentialing.

3.         Each program shall provide written guidelines for educational interventions for deficient medical records in the program’s Resident/fellow Handbook.  The department guidelines will fall within the parameters of this policy.

A.        Upon notification of deficient records, the Program Director or designee will contact the resident/fellow to determine a plan for completion of deficient records in a timely manner. 

B.        If deficient records are not completed within above-determined time period, the Program Director will inform the resident/fellow in writing of educational interventions including but not limited to:

·       The program’s written plan for educational interventions for deficient medical records which will include C & D below,

·       the patient records in need of completion,

·       the time frame for completion,

·       the educational intervention {i.e. a pamphlet which ties completion of records to competencies education.  Or the ECFMG website has a scenario/vignette, questions about that scenario and a follow-up explanation.  It touches on how medical records are a part of patient care, systems-based practice, professionalism, interpersonal communication, and how legally important timely records are.}

·       Exploring the cause for the deficient records for social or health interventions on behalf of the resident/fellow, practice-based errors, communication skills errors, professionalism, systems-based practice errors.    

C.        If the resident/fellow fails to complete the records within the stated time frame, the GMEC policy 1.420 on Academic and Other Disciplinary Actions, will be enacted. 

The program director shall notify the resident/fellow with a written statement to include:

1)      The suspension is due to continued deficient medical records after previous intervention (give date of written document discussed in A and B above).

2)      The resident/fellow will be placed on “administrative leave” from clinical duties, with pay, for a limited time frame with the expectation that records are completed (state time frame in letter). 

3)      Activities of the program in which the resident/fellow may and may not participate until the records are completed.

4)      The date the suspension becomes effective.

5)      Consequences of non-compliance with the terms of the suspension (see D below).

6)      Whether or not the resident/fellow is required to spend additional time in training to compensate for the period of suspension and be eligible for certification for a full year.

A copy of the statement of suspension shall be forwarded to the Associate Dean for Graduate Medical Education and the Director of Housestaff Records.

D.        If, after the suspension, the records are not completed, a Program Director may initiate additional consequences.  These consequences may include, but are not limited to, the following:

·       Ratings on evaluations and terminal information about resident/fellow’s training will be documented as unacceptable such that future requests for credentialing, board eligibility and licensure will be informed

·       Deductions from educational funds

·       Loss of privileges of the training program

·       Suspension without pay

·       Dismissal

·       Withholding of training program certification

·       Monetary fines

The Program Director must notify the Associate Dean of Graduate Medical Education in writing of any additional consequences initiated against a resident/fellow.