Resident and Fellow Policy ManualAppendix 1 - Procedure for Delinquent Medical Records:The Strong Memorial Hospital Policy 6.1.1 (revised 11/06) states that: In the case of resident physicians, failure to complete delinquent aspects of the medical record within the communicated timeframe will result in the suspension of the privilege to participate in all clinical activities associated with their residency requirements. This time will be made up through the use of vacation time or through continuing the residency beyond the scheduled completion date without payment of an additional stipend. Repeated delinquencies may result in further disciplinary action. 1. A patient’s medical record is considered delinquent when:
The attending providers will be contacted throughout the work week when operative reports are identified as incomplete. Providers will be expected to complete the operative report immediately after notification. If the operative report remains undictated the work day following the notification, the attending provider will be suspended. When suspension of a resident or fellow occurs for failure to complete the record timely, the resident or fellow loses all clinical privileges and malpractice insurance at all affiliated hospitals and other training locations. Suspension time does not count towards training requirements. Lost time must be made up either with the use of vacation or at the end of the residency or fellowship with no additional stipend. Suspension and restoration of privileges will be coordinated through the Office of the Chief Medical Officer for Strong Memorial Hospital. The Office for Graduate Medical Education, Department Chair and Program Director will be notified of all suspensions and reinstatements of residents. Restoration of privileges will occur when the resident has completed the delinquent record (s). Documentation of the suspension will become part of the resident’s permanent institutional file. Physicians will not have their privileges suspended for circumstances beyond their control; i.e., illness, vacation, inability of the Health Information Management Department to locate the record, or failure of the dictation or transcription system. Physicians must notify the Health Information Management Department in a timely manner regarding any vacation, illness, or leave of absence. At Strong Memorial Hospital, records are available 24 hours a day, 7 days a week. Call ahead to make sure the record is in the Health Information Management Department. For incomplete records, call 275.5498; for research or review, call 275.2602 At Highland Hospital, the charts are available at all times. Official hours are 7:30 AM to 8:00 PM Monday through Friday and 9:00 AM – 1:00 PM on Saturdays. During the times that the department is not open, providers can obtain a key from the switchboard/communications office to get into the department. If a resident knows that the department will be closed when they want the chart, it is best to call ahead to 341.6766 and request to have the chart(s) pulled and ready for pick up. Approved by GMEC 10/20/97 Updated and Approved by GMEC 7/13/98 Updated and Approved by GMEC 12/14/98 SMH Policy 6.1.1 updated 6/2002 SMH Policy 6.1.1 updated 3/2005 SMH Policy 6.1.1 updated 11/2006
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