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TOPIC:

 

House Staff Compliance with Timely Completion of Medical Records

PURPOSE:

 

To outline a process for timely completion of medical records (MR) by the House Staff at Advocate Illinois Masonic Medical Center (AIMMC); define terms and outline responsibilities and procedures involved to ensure compliance with this policy; and provide a process that holds residents accountable for their role in the timely completion of patient records to facilitate appropriate continuity of patient care and ensure AIMMC’s ability to meet regulatory expectations on MR completion.

POLICY:

 

House Staff will be required to complete all elements of the Medical Record for which they are responsible within fifteen (15) business days of patient discharge.

Procedure

Residents must complete all elements of the Medical Record as directed by AIMMC’s Medical Staff Rules and Regulations.  Such items of completion include signing of the history, physical, operative notes, and verbal orders. These items also include dictating the discharge summary and operative report.  Failure to do so may result in negative evaluations citing failure to meet proficiency in the core competency of professionalism.  In addition, requests for verification of affiliation or education during search for employment will include a reference regarding timely MR completion.
 
Department-specific methods may be used to ensure compliance with this policy. Programs choosing to develop a different process from that prescribed within this policy, should obtain approval from the Education and Research Committee before implementation.

All Residents should adhere to the following guidelines:

  1. All residents will have immediate notification of, and access to, all MR items requiring dictation via their electronic MR Inbox.
  2. In addition, the Health Information Management Department (HIM) will assure multiple notifications of items requiring completion of patient documentation by using the following steps:
    1. All incomplete patient documentation will remain visible in a user's MR Inbox until dictated.
    2. Every Wednesday, HIM staff hand-deliver lists of all deficiencies including delinquent records to the Residency Program Directors (PDs) for final notification to the responsible residents. At this point, following notification by the PDs, the resident must complete the records within five (5) business days.
  3. The PDs are encouraged to use the following steps with residents who have delinquent items reported:
    1. Verbal counseling – For the first occurrence, the PD will meet with the resident to detail the concern, including the date of the event. The resident’s explanation will be heard and documented.
    2. Letter of formal counseling – For the second occurrence, the PD will inform the resident of the delinquency incident, document the details of the concern in a formal letter of counseling and then meet with the resident to discuss the event and expectations for resolution.
    3. Formal counseling reevaluation – The PD will meet with the resident for reevaluation three months following the second occurrence or sooner if another delinquent record incident occurs. If the meeting is a result of a third incident, the information will be documented in a formal letter to be signed by both the PD and resident, and forwarded to the Department Chairman for signature. If the resident shows persistent deficiency in ability to meet this professional proficiency or other core competencies, the PD may determine the need to engage disciplinary steps as determined by the program and may result in actions such as program-level remediation and subsequent formal probation.

Approved by Education and Research Committee 06/03/09

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