Medical Records Completion Protocol
Accurate and timely completion of medical records is a core physician competency and demonstrates professionalism. In an effort to keep medical records complete and current the Graduate Medical Education Committee at SIU School of Medicine has approved the following procedures. HSHS St. John’s Hospital, Memorial Medical Center, and SIU Medicine will work in conjunction in this effort, so that a resident with delinquent records at either hospital or any SIU Clinic will be managed in accordance with a similar process, including notice of delinquent status, and, if necessary, clinical or disciplinary suspension.
Hospital Medical Records
Every week HSHS St. John’s Hospital and Memorial Medical Center will evaluate the completion status of medical records. Residents having incomplete medical records for 10 or more days will be identified, and an email notification with specifics will be sent directly to the resident from the medical records department (MRD) staff (this is “day 1”).
One week later, the list of delinquent residents and medical records will be checked for completion by the MRD staff.
On the same day, the MRD staff will email the “NOTICE OF DELINQUENCY AND IMPENDING SUSPENSION” to the SIU Office of Graduate Medical Education (OGME) stating that the resident must complete his/her medical records within seven days or face SUSPENSION from clinical duties and training rotations. Such suspension will be a minimum of twenty-four hours and will result in loss of privileges until the delinquent medical records are completed. OGME will notify the Program Coordinator of the approaching delinquency and impending suspension.
During the following seven day period, delinquent medical records will be monitored and MRD staff will email OGME with an update at the end of the seven day period. A resident’s delinquent status will be lifted when the medical records are completed.
Any resident who has not completed his/her medical records by noon of this notification day will be suspended from hospital privileges, clinical duties and training rotations until the medical record obligation is met and/or for a minimum of twenty-four hours. If the determination is made that suspension is necessary, SIU OGME will be immediately notified, and in turn notify the Program Coordinator and Program Director that SUSPENSION will start on the following day at 0800 or during the resident’s next duty period. SIU OGME will notify the resident’s employing hospital that the resident has been placed on Suspension with pay. A resident cannot use vacation or leave time to make this time up and this will count toward days away from clinical training.
Once the medical records are completed, the MRD staff will notify OGME, who will in turn notify the program when the resident can return to work.
SIU Medicine Clinic Medical Records
Each clinical department and training program will develop appropriate internal standards for resident completion of medical records in SIU Medicine clinics. Programs will ensure that the policies are consistent with the SIU Medicine Medical Records Completion policy and outline expectations for resident medical records completion, methods of notification and consequences of delinquency up to and including clinical suspension. For SIU Medicine clinic records, all medical record monitoring, notices of delinquency and decisions regarding clinical suspension are the responsibility of the program. As with HSHS St. John’s Hospital and Memorial Medical Center, program suspension for SIU Medicine clinical records delinquency will last a minimum of twenty-four hours, will be with pay and will include suspension from hospital privileges, clinical duties and training rotations until the medical record obligation is met.
The program coordinator will notify the Office of Graduate Medical Education by noon on the date of suspension. SIU OGME will notify the resident’s employing hospital that the resident has been placed on suspension with pay. Once clinic medical records are completed, the program coordinator will notify SIU OGME that the suspension has been lifted, and will report the exact dates of suspension that the program has on record.
If a resident incurs 3 instances of clinical suspension, he/she will then receive a 7-day disciplinary suspension with loss of clinical/hospital privileges, clinical credit and pay. This 7-day disciplinary suspension will be scheduled by the resident’s Program Director at a time when it is least disruptive to the program and will in all likelihood result in a delayed graduation date. OGME will notify the hospitals of the scheduled suspension without pay.
If a resident incurs an initial 7-day disciplinary suspension, any subsequent instances of clinical suspension will result in an additional 7–day disciplinary suspension.
TIMELINE FOR HOSPITAL RECORDS
Refer to the attached PDF that outlines the timeline for hospital medical records.