GME P&P Medical Records

	GRADUATE MEDICAL EDUCATION POLICIES & PROCEDURES Graduate Medical Education Policy For Completion of Medical Records At Texas Health Presbyterian Hospital Dallas	Policy Number: 13
		Date Issued: 01/2003
		Prior Revision Date:10/2010
		Date Revised:

PURPOSE

To establish a procedure to assist in monitoring the completion of medical records by house staff.

SCOPE

All medical students, interns, residents and fellows (hereafter all will be
referred to as trainees) participating in graduate medical education training programs at Texas Health Presbyterian Hospital Dallas.

PROVISIONS

In order to facilitate the completion of medical records, the Health Information Management Department (medical records) is open and staffed 24 hours a day, 7 days a week. Trainees must comply with the same timing and content requirements for medical record entries as are required of members of the medical staff as defined in the Medical Staff Rules and Regulations. These requirements are provided during orientation. Trainees are required to complete the medical record of a discharged patient within twenty-one (21) days following availability after discharge. Failure to complete a medical record within the prescribed time frame shall result in notification to the Program Director for action as defined in departmental policy. Completion of medical records will be taken into consideration as part of the resident’s evaluation and consideration for promotion or completion of the program.

REFERENCES

Medical Records “Health Information Management; Department of Information” Packet

LESLIE H. SECREST, MD
Medical Director, Graduate Medical Education

AURORA ESTEVEZ, MD
Chief Medical Officer