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TOPIC:

 

Medical Record Completion

PURPOSE:

 

To facilitate completion of the medical record by the Attending staff, residents/ fellows must complete discharge summaries and operative reports in a manner that allows for medical staff review and signature within 30 days

POLICY:

 

Resident/fellow in-patient medical records must be completed with 15 days of patient discharge.

Procedure

  1. An in-patient medical record is considered delinquent if it has not been completed on or before the 15th day following patient discharge.
  2. Residents/fellows will be encouraged to dictate discharge summaries from the patient care area.
  3. Discharge summaries can also be dictated from any phone (in or out of hospital) using the Lanier dictation system and accessing the patient record via portal access to Care Connection.
  4. It is expected that operative reports will be dictated the day of the procedure.
  5. A list of "To Be Dictated" reports is easily available to the resident/fellow on line via Care Connection/Profile/Provision.
  6. Program Directors will receive a weekly list from the Health Information Management Department detailing their resident delinquent charts -- greater than 15 days up to and including greater than 120 days.
  7. Each Program is expected to have their own Program medical records completion policy, consistent with institutional policy, which will include measures to monitor and ensure resident/fellow compliance.

Approved by Education and Research Committee 06/06/07

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