Wright State University School of Medicine
Sponsored Graduate Medical Education Programs
Resident Manual

Item 403
Medical Records Completion
Revised July 1996

All School of Medicine (SOM) sponsored residents must observe the following practices when rotating among hospitals or when graduating from the SOM program. These practices refer to completion of medical records at all teaching hospitals that are listed in accreditation documents as supporting any of the SOM-sponsored programs. This policy will ensure that medical records are completed in a timely manner by responsible SOM residents in order to assure the continuity of patient care and billing for hospital services.

Procedure
1. When rotating for training among teaching hospitals:

a. residents and programs must be aware of individual hospital policy on record completion, including any disciplinary procedures,

b. incomplete or delinquent records remain the individual resident's responsibility,

c. programs will assure record completion by the resident by implementing appropriate policies that allow the resident or a designee time to complete records.

2. When graduating from SOM-sponsored GME programs:

a. residents must notify the program director or director (department) of medical education of planned departure at least five working days in advance of that departure date,

b. the "Resident Route Out" procedure will be completed (route out slip completed),

c. incomplete medical records are the resident's responsibility.

3. Residents must always ensure record completion in a timely fashion. Completion of records can usually be assured by a visit to the medical records department every two weeks.

4. Residents should notify program directors/directors of medical education of any circumstance preventing timely completion of records.

5. Programs must have a policy that is compliant with that of their training that will assure timely completion of resident medical records.

6. Hospitals must have a policy to keep residents and programs continually informed about incomplete or delinquent medical record status, and must make every effort to assure record availability for completion.

NOTE: A specific time frame has been developed in the office or department of medical education in each training hospital for completion of delinquent medical records. Residents must familiarize themselves and comply with medical records policy at each teaching hospital or institution in which they train and participate in patient care. The medical education department in each hospital should provide monthly lists of residents leaving the training site to the records departments.

Wright State University Residency Program
Resident Route-Out Slip
for
Medical Record Completion

This is to certify that you have completed all available medical records at (Hospital Name) as of today's date.

However, you are responsible for completing any subsequent records which are assigned to you. You will be notified within 21 days from today of these records needing signature and/or dictations. You then have up to 35 days from today's date to complete these records. There is, however, no time limit on completion of missing dictations. You will always be responsible for dictation of those reports.

Failure to comply with the above will result in a letter reflecting noncompliance which will be forwarded to your permanent file at Wright State University.

Route-out approved _____Yes _____No

_________________________________ Medical Record Director Signature	_________________________ Date
(or designee)
_________________________________ Resident Signature	_________________________ Date
(or designee)

cc:	Director, Medical Education Hospital Program Director Wright State University Residency Program Resident

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