Medical records completion policy

Scope

This policy was developed for SIU Medicine. SIU Medicine collectively applies to the SIU School of Medicine (SIU SOM), including the Federally Qualified Health Center (FQHC), and SIU HealthCare (SIU HC). These entities are collectively referred to as SIU in this document.

This document applies to SIU staff, faculty, trainees, agents, officers, directors, interns, volunteers, contractors, and any other individual or entity engaged in providing teaching, research and health care items and services at SIU. These individuals are collectively referred to as SIU personnel in this document.

Definitions 

The term “resident” is inclusive of all trainees at SIU SOM, whether training in a residency or fellowship program.  The term “program” is inclusive of all SIU residency or fellowship programs, whether accredited or non-accredited.

Purpose

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.

Procedure

CONSEQUENCES FOR DELINQUENT MEDICAL RECORDS

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 completion of medical records and tasks, including methods of notification and consequences of delinquency, up to and including clinical suspension.  For SIU Medicine clinic records and tasks, all monitoring, notices of delinquency and decisions regarding clinical suspension are the responsibility of the program. Program-level 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 or their delegate 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.  

A resident cannot use vacation or leave time to make this time up and this will count toward days away from clinical training.

Hospital Medical Records 
Residents in all programs must adhere to the medical record policies, requirements and protocols, including suspension or other consequences for delinquency, of affiliated hospitals and any clinical site in which they rotate.

For Springfield Residents Only
For Springfield residents, due to the number of programs and cross-hospital rotations, SIU Medicine, HSHS St. John’s Hospital and Springfield Memorial Hospital will collaboratively monitor records using the process outlined in the Springfield Hospital Medical Records Completion Procedure, so that a resident with delinquent records at either Springfield hospital will be managed with a similar process, including notice of delinquency status and suspension, if necessary.

DISCIPLINARY SUSPENSION

If a resident incurs 3 instances of medical records suspension for hospital or SIU Medicine Clinic delinquency, the program may then impose 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 may 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 may result in an additional 7–day disciplinary suspension.

A disciplinary suspension is an Action that may require disclosure to others upon request, including but not limited to privileging hospitals, licensure or specialty boards. If a resident is subject to disciplinary suspension, they must be notified of this in writing, signed by the Program Director and the DIO/Chair of GMEC, and accompanied by a copy of the Due Process and Resident Complaint Policy.  A resident who incurs a disciplinary suspension may request a review of the decision as described in the Due Process and Resident Complaint Policy.