Medical Records

POLICY: MEDICAL RECORDS

PURPOSE:

To establish an institutional policy regarding the medical records system for the graduate medical education programs within the institution.

POLICY:

The medical record reflects the quality of patient care given in a hospital. The record is the basic tool for planning patient care and for communication between physicians and other persons contributing to patient care. The medical record must document the course of each patient's illness and care and must be available to the residents at all times. The medical records system must support the education of residents and quality assurance activities and provide a resource for scholarly activity.

Orientation regarding the institution's medical records systems may be found in program manuals. It is also delivered orally by the Director of Risk Management and Medical Records departments at the House Staff Orientation for all incoming trainees at Orientation, and in the Rules and Regulations of the Medical Staff Bylaws. In addition, the Medical Records Committee, established to monitor the quality of documentation in the medical record, has a resident representative.

Rules and Regulations regarding Delinquent Records. Section 9 (l)

Residents who do not complete their medical records within 30 days of discharge will receive a letter warning them that they have 14 days to complete their records or they will be suspended from clinical duties. 14 days later, any resident that has not completed all available incomplete charts will be automatically suspended. The suspension will remain in effect until all charts are completed. Suspensions will be reported on the resident final evaluation.

Fines will be imposed for all house staff suspensions as follows:

1st suspension - no fine
2nd suspension - $10
3rd suspension - $50

Residents are responsible for notifying the supervisor in the incomplete room (444-2854) once the records are complete. Additional information: Refer to ADMINISTRATIVE POLICIES & PROCEDURES MANUAL Management of Information (IM).

Reviewed: November 18, 2003
Revised and Accepted: November 24, 2003