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Internal Medicine Policies & Guidelines

VCU Internal Medicine Training Program
Delinquent Medical Records Policy (Adapted from the VCUHS policy)

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  1. Purpose:

    To ensure that medical record deficiencies are completed within established institutional guidelines to facilitate data for continuity of patient care, financial reimbursement and to meet the Standards of the Joint Commission on the Accreditation of Healthcare Organizations.

  2. Policy:

    Appropriate actions will be taken with respect to Attending Physicians who become delinquent in completing medical record deficiencies within specific time frames. As a result, it is necessary that the Housestaff of the Internal Medicine training program complete medical record deficiencies in a timely fashion so that the responsible attending physician does not become delinquent.

  3. Definition of Terms:
    1. Medical Record Deficiency - Any discharge summary not dictated for an admission with a length of stay greater than 23 hours at MCVH or for ANY admission (including those with a length of stay less than 23 hours) at the VAMC.
    2. Delinquent Medical Record Deficiencies - A discharge summary not dictated within 7 days of an inpatient discharge or death.
    3. Readily Available Medical Records - Records located by the Department of Health Information Management within 24 hours of the physician's request.(The physician may specify when within the 24-hour period he/she would like to return to complete the record deficiencies.)
    4. Responsible Physician - Attending physician of record at patient discharge is ultimately responsible for the dictation of Discharge Summary. However, it is the responsibility of the Housestaff physician (either intern or supervising resident) to ensure that the dictation is completed as part of their role on the inpatient team. Interns should complete the discharge summaries for all of their patients. However, it is ultimately the responsibility of the supervising resident taking care of the patient ensure that the discharge summary is completed.
    5. Appropriate Location for Medical Record – If a discharge summary is dictated but not designated as a “discharge summary” in the medical record, that document will be considered delinquent by both MCVH and the VAMC. Both institutions have defined procedures for designating Discharge Summaries in the medical record. It is the responsibility of the supervising resident to ensure that interns place their documents in the appropriate folders within the Electronic Medical Record.
  4. Procedure
    1. Notification and Action
      1. At MCVH, if a discharge summary is not in a patient’s chart within 7 days from date of patient discharge, CERNER will automatically notify the responsible intern and attending physician that a disciplinary action will result if the situation is not corrected. Therefore the Attending Physician has 7 days after notification to complete the record before sanctions are enforced. Any faculty member who has a delinquent medical record will be subject to suspension of privileges and/or employment after proper notification and a period of time necessary to complete the records. The sanction policy will be available in the office of the departmental chairman and the Chairman, The Chief Medical Officer and the Executive Committee of the Medical Staff will implement specific features.
      2. At the VAMC, the Department of Health Information Management will compile a list of all housestaff who have medical record deficiencies as of 9:30 pm each Monday. Since there is a delay of up to one day in deleting delinquent records from the list, this list essentially contains all physicians who have any incomplete records as of Monday morning at 7 am. This list will be faxed to the Office of Educational Affairs on Tuesday morning at 9 am and distributed to the chief residents. An e-mail will be sent out on Tuesday listing all housestaff who have medical record deficiencies accompanied by the number of deficiencies that are considered delinquent (more than 7 days from the date of discharge). This will be considered a warning.
      3. The housestaff physician will have 6 days from the date of the warning e-mail (until Monday morning at 7am) to complete the delinquent medical records. If after this time period, the housestaff physician still has not completed the delinquent records, an e-mail will be sent from the chief resident to the Program Director, requesting that a letter of concern be placed in the housestaff physician’s file regarding this issue of professionalism.
      4. A Chronic Offender, who has received multiple letters of concern within a 6 month period, may be brought before the Clinical Competency Committee
    2. Clarification
      1. If housestaff physicians request a record (which is not available in the electronic medical record) for review in order to complete a discharge summary and this record is not readily available, they will not be penalized as above. Instead, they should continue to check back with the Department of Health Information Management on a weekly basis to see if the record is available. As soon as the record becomes available, the housestaff physicians will be required to complete the record within 7 days or the action listed above will take place.
      2. The Department of Health Information Management is fully staffed Monday through Friday from 8:30 am – 5:00 pm. Limited assistance is available after hours, weekends, and holidays. However, if you are in need of a record that you plan to dictate at a later time period (especially during the weekend), please call them during business hours at 828-9021 to locate the record and have it set aside for you.
      3. If you have any questions or believe that there is a discrepancy regarding your incomplete medical records at MCVH, please, call 828-9021 to clarify. If you have any questions or believe that there is a discrepancy regarding your incomplete medical records at the VAMC, please contact Lillie Floyd, VA ext 5832.

REVISED DATE: 8/18/2011
REVIEWED DATE: 10/27/14
ISSUED BY: Stephanie A. Call, MD, MSPH, Daniella Schwartz, MD

 
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