Department of Medical Education
GE 35
| TOPIC: |
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Medical Record Completion |
| PURPOSE: |
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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: |
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Resident/fellow in-patient medical records must be completed with 15 days of patient discharge. |
Procedure
- An in-patient medical record is considered delinquent if it has not been completed on or before the 15th day following patient discharge.
- Residents/fellows will be encouraged to dictate discharge summaries from the patient care area.
- 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.
- It is expected that operative reports will be dictated the day of the procedure.
- A list of “To Be Dictated” reports is easily available to the resident/fellow on line via Care Connection/Profile/Provision.
- 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.
- 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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