Resident File Management

DEPT: MEDICAL EDUCATION
POLICY #: 8240.35

GOALS

Resident files serve as both records of employment and academic program records. They are the primary source used for verification of training throughout the Resident’s career. As such, they must be accurate and contain all information needed for licensure and application for credentialing. The files also serve as a record of a Resident’s performance and competency. To ensure that all Residents trained at Cottage Health have training records that support their future needs, a uniform policy of minimal standards for records management is implemented.

POLICY

This policy recognizes three categories of Residents:

1. Individuals that apply for the program but are not interviewed for a program position;

2. Individuals that apply and are interviewed for the program but do not match/enroll in the program; and

3. Residents who are accepted into a program.

A) Program Applicants: It is important that an accurate description of the applicant pool is maintained for a minimum of three years. This can be most effectively accomplished by maintaining each application (either electronically or in hard copy). The application includes the standard application form plus all supporting documents (personal statement, exam scores, letters of recommendation).

B) Interviewed Applicants: All records pertaining to interviewed applicants must be maintained for a minimum of three years. In addition to the full application and supporting documents, this would typically include interview evaluation forms used by the program to obtain feedback from program faculty and Residents about each applicant.

C) Program Resident: Resident files are kept in three categories:

1) Employment and immigration records maintained by Cottage Health Human Resources;

2) Contract, credentialing, and academic records maintained by GME; and

3) Health records maintained by Employee Health and Safety within Cottage Health Human Resources.

GME Programs will be responsible for maintaining records related to Resident academic program participation, completion, and medical licensure. The required elements of the GME Resident file should include:

1) Documentation of medical school graduation (diploma)

2) Proof of name change (if applicable)

3) Agreement of Appointment (contract)

4) Documentation of current training or permanent licensure (state medical license)

5) DEA Certification (if applicable)

6) Documentation of Education Commission on Foreign Graduate Medical Education (ECFMG) certification for international medical graduates (if applicable)

7) Certificate of Completion

8) Consent for release of information

9) Certificate of Insurance (malpractice)

10) Written performance evaluations from multiple evaluators, including faculty, self, and others, as specified in the Program Requirements

11) Semi-annual (more frequently if required by the specialty Review Committee) evaluations (competency and milestone-based) by the Clinical Competency Committee

12) Semi-annual summary evaluations from the Program Director or his/her designee

13) Record of resident rotations

14) Record of resident surgical and procedural training

15) Record of required added training, such ACLS, PALS, etc.

16) Record of scholarly activity and quality improvement projects, including records of presentations, abstracts, and publications

17) Record of Moonlighting approval form (if applicable)

18) Record of any corrective action or educational disciplinary actions, as pertinent to the particular resident

19) Documentation of prior training and performance evaluation (for transferring Residents)

20) Any other content as determined by the program director, Sponsoring Institution, or training program accrediting organization

PROCEDURE

Secure Storage
Resident files may be contained in an electronic system, or in a combination of paper and electronic records. Secure storage to prevent loss of records, and electronic file back-up and recovery protocols must be in place and consistently followed:

1) For Program Applicants: Residency coordinators will retain electronic files in the Electronic Residency Application System (ERAS).

2) For Interviewed Applicants: Residency coordinators will retain electronic files in ERAS for the previous three years.

3) For GME resident files containing contracts, credentialing, and academic records, program coordinators/administrators will manage oversight of

a) file scanning (by an appropriately credentialed volunteer or staff)

b) uploading to a program shared drive, and

c) conducting an audit of at least every 5 files to ensure completeness

4) A Cottage Health approved encrypted Data Locker will be used for secure storage

a) Semi-annually, the DIO, Program Director, Program Coordinator/Administrator or his/her designee will update the Data Locker and keep it at an off-site location to prevent loss of records.

Indefinite Retention
Standards for document retention will be based on Cottage Health, the state of California, and other relevant entity requirements. At a minimum, from an accreditation perspective, Cottage Health will indefinitely retain the following core files for all residents who successfully complete the program in order to accommodate future requests for primary source verification of program completion:

1) A summation of the Resident’s final summative evaluation, certificate of completion (diploma), and the letter from the Program Director indicating readiness for unsupervised practice;

2) Records of the Resident’s rotations, training experiences, and procedures, as applicable to the specialty.

3) Certificate of Insurance (malpractice); and,

4) Documentation of disciplinary action if any

For residents who do not complete the program or who are not recommended for Board certification, programs should keep the entire file for a minimum of seven years in case of subsequent legal action.

Disposal and Archive
Paper files may be scanned and kept electronically as outlined in Secure Storage above, with appropriate disposal by shredding.

COTTAGE HEALTH POLICY

Original Policy Effective Date: 10/2023
Owner Title: Vice President Medical Affairs (VPMA)
Owner Approval Date: 10/2023
Committee Approval: Graduate Medical Education (GMEC)
Committee Approval Date(s): 10/2023
VP Approval: CMO/VPMA
VP Approval Date: 10/2023