Colorectal Surgery Resident Manual

PROTOCOL FOR SUSPENSION OF RESIDENTS WHEN MEDICAL RECORDS ARE DELINQUENT

In an effort to keep hospital medical records complete and current at Memorial Medical Center and St. John’s Hospital, the Graduate Medical Education Committee at SIU School of Medicine has approved the attached policy. The procedures outlined below will be followed to assure compliance with this policy.

Every week 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. On the following day, day 1, a notice will be sent to the resident and copied to the program director.  One week later, on day 8, delinquent residents will be paged and advised that their medical records must be completed by 0800 3 days hence or they will be placed on PROBATION status.

On approximately Day 10, the list of delinquent residents and medical records is checked for completion.  The Program Director of each delinquent resident will receive a phone call advising of any resident to be placed on PROBATION.

That same day the hospital coordinator will fax the “NOTICE OF PROBATION AND IMPENDING SUSPENSION” to the Program Director and the SIU Office of Residency Affairs 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 result in loss of privileges and pay until the delinquent medical records are completed.  The Program Director will sign the acknowledgement and fax it back to the hospital coordinator. 

During the following seven day period, delinquent medical records will be monitored daily and program directors will be notified when the resident has completed the medical record obligation.  A resident’s probationary status will be lifted when the medical records are completed.

Any resident that has not completed his/her medical records by noon of approximately day 18 will be suspended from hospital privileges, clinical duties and training rotations, and will be placed in no-pay status until the medical record obligation is met. If the determination is made at noon on Day 18 that suspension is necessary, the Program Director and the SIU Office of Residency Affairs will be immediately notified.  SUSPENSION will start on the following day at 0800.  The SIU Office of Residency Affairs will notify the HR department of the resident’s employing hospital that the resident has been placed on Suspension without Pay.

Once the medical records are completed, the hospital coordinator will notify the Program Director and the SIU Office of Residency Affairs that the suspension has been lifted.  The hospital coordinator will notify the Office of Residency Affairs of the number of days that the resident has forfeited pay due to suspension for delinquent medical records. The SIU Office of Residency Affairs will notify the employing hospital of the number of days that the resident was unpaid.

The resident cannot recover pay that is forfeited due to suspension under this policy.  This pay is permanently lost to the resident.

The last moment that a resident can complete records and avoid suspension is noon on Day 18.  If suspension is instituted it will take effect the following day, Day 19, and will remain in effect until records are completed.  The minimum duration of suspension is one day.

St. John’s Hospital and Memorial Medical Center will work in conjunction in this effort, so that a resident who is employed by one hospital, but with delinquent records at the other hospital, will be managed in accordance with the same process, including notice, probation, and, if necessary, suspension.

The following diagram outlines the process.  The process and intervals are the same at Memorial and St. John’s, although the days of the week may vary between the two hospitals.

Sample Calendar—actual days and intervals may differ slightly between Memorial and St. John’s

Amended and Approved by IRACC, September 18, 2007
Amended and Approved by GMEC, September 21, 2007

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