Resident Physician Records Delinquency Policy

DEPT: MEDICAL EDUCATION

POLICY #: 8240.05

GOAL

To allow implementation of action in cases of Resident staff medical record delinquency as outlined for the medical staff in the medical staff bylaws and as required by governmental legislation.

POLICY 

1. Members of the resident staff are required to complete medical records within two weeks of the time such records are made available to the resident by the Medical Records Department. Failure of timely chart completion will result in placement of offenders on the medical record delinquent list.

2. Residents who continue on the delinquent list will be subject to further action:

a) At two weeks after the records are made available, the Resident will receive a warning letter. A copy of this letter will be placed in the Resident’s file but will be removed if the medical records are completed within four weeks from the time of availability of the records (i.e. within two weeks from the date of the warning letter). If records are not completed within that time frame, a permanent letter will become part of the Resident’s file.

b) At three weeks after the records are available, the Resident will receive a second letter. This letter will:

i) Warn the Resident that he/she will receive a permanent letter in one more week if the records are not completed, and

ii) Mandate that the resident attend the next Graduate Medical Education Committee (GMEC) to explain why his/her medical records cannot be completed in a timely manner.

c) At four weeks after the records are available, the Resident will receive a letter informing him/her of probationary status as a Resident; a permanent copy of this letter will be entered into the Resident’s file.

d) After three weeks on probation, if the records are not completed, a disciplinary process will be initiated. This process will follow the procedure outlined in “Resident Physician Grievance Procedure” and may result in termination.

e) Any Resident who on three separate occasions receives the second letter (described in 2.b above) with its required GMEC appearance, will have a permanent letter placed in his/her file describing the Resident’s deficiency in completing medical records.

3. Bona fide vacation or illness may constitute an excuse subject to the approval of the GMEC.

COTTAGE HEALTH POLICY

RECOMMENDED BY: E. Wroblewski, M.D. (CMO). DATE: 11/14
ORIGINAL POLICY EFFECTIVE DATE: 3/94
APPROVED BY: E. Wroblewski, M.D. (CMO) DATE: 11/14
DATE REVISED: 3/96
DATE REVIEWED: 3/96, 3/00, 4/01, 6/07 , 1/12, 11/14