VCU Internal Medicine Training Program
Procedures Documentation and Tracking System
Printable version of the Procedure Documentation and Tracking Policy (pdf)
Procedure Requirements
All documentation and tracking of resident procedures is done electronically through New Innovations. The following procedures will be tracked by the training program; asterisk indicates that the ABIM requires documentation that one can perform this procedure safely and competently. See ABIM website for full details on procedure requirements.
The ABIM requires knowledge and understanding of indications, contraindications, complications and technique of all others listed (except bone marrow, chest tube, intubation and swan-ganz catheter placement).
The program requires a minimum of at least 3 of all procedures indicated with a #. In order to qualify as a supervisor, the program requires 5 thoracenteses, subclavian lines, and internal jugular lines.
- Abdominal paracentesis#
- ABG/arterial puncture* #
- ACLS*
- Arterial line placement
- Arthrocentesis #
- Bone marrow aspiration or bx
- Central venous line placement (subclavian or interial jugular)#
- Chest tube
- EKG interpretation#
- Endotracheal intubation#
- Flexible sigmoidoscopy
- Lumbar puncture#
- Nasogastric tube placement
- Pelvic exam with pap smear* #
- Peripheral venous line* #
- Swan Ganz Cather placement
- Thoracentesis #
- Venous blood drawing* #
** EKG interpretation should be credited to each pgy-1 resident after completing rotation in cardiology; peripheral venous line will be credited to each PGY-1 after peripheral IV line training.
All procedures MUST be supervised by a physician who has supervisory capacity. This includes attending physicians, fellows and senior residents who have successfully completed at least three of the procedures in question. Supervisors may be from any Department.
Procedure Documentation
All procedures must be entered into the electronic tracking system (New Innovations). When a resident completes a procedure, they should document a procedure note in the patient chart AND enter the procedure into the web-based system. At this time they must indicate:
- Resident name
- Date
- Patient name and medical record number (confidentially blocked out in system)
- Procedure completed
- Supervisor
- Indication for procedure
- Diagnosis
- Complications
Once the entry is complete, it is electronically forwarded to the supervisor for sign-off. The procedure is not logged into the system as completed until it is signed off.
A resident performing a procedure may be unable to identify their supervisor in the system for two reasons – 1) the supervising resident has not completed enough procedures in order to supervise (#3 of each procedure) or 2) the supervisor is not in the system for technical reasons – non-Internal Medicine Dept, etc. In the first scenario, the resident performing the procedure cannot get “credit” for the procedure. In the second case, the resident should enter the procedure under the program director’s name in the electronic system, then submit a paper version of the procedure documentation (with supervisor signature) to the program director’s office (ABIM procedure tracking books OR procedure tracking form available on ERIC). The program director will sign off on the procedure once it is verified in written form.
ABIM eligibility
At completion of the program, the program director will submit an evaluation of procedural competency for each resident to the ABIM (included in the yearly ABIM tracking evaluation form). If a resident has not completed and documented the ABIM procedure requirements, this evaluation will be unsatisfactory and the resident will not be eligible to sit for boards.
Hospital verifications
The program director will use the electronic summary report to document completed procedures for all hospital verification forms when requested.
