Quincy Family Practice Program Residents Manual
Medical Record Policy
This policy only pertains to Quincy Family Practice Center as Blessing Hospital has its own Medical Record Policy.
STATEMENT OF PURPOSE
Timely medical record completion is critical to proper patient care. It facilitates interphysician communication and coding and billing. The ideal technique for medical record completion is to dictate after each patient visit. Many times this is difficult and it is strongly suggested that records be completed before leaving clinic that day. Under no circumstances should charts be delinquent by more than 48 hours.
DELINQUENT CHARTS
Delinquent charts will be defined as charts which do not have dictation for a patient visit within 48 hours of that visit.
POLICY
If a resident is identified to have delinquent charts, the Program Director, and/or his/her designee will contact the resident. Initially, education will be given regarding the importance of chart completion, advice on the best way to complete records and any additional assistance will be provided. If this becomes a persistent problem, a letter will be sent to that resident as well as a copy to that resident's permanent file. If no additional deficiencies are identified, that letter will be removed at the next resident and Program Director review.
If additional delinquencies occur, a second letter will be sent. At the time of the second letter, the resident will be suspended from all office and clinical duties until all records are completed. The suspension time will be additional time in the residency and cannot be vacation and/or education leave (the resident will be informed at the time of the initial letter that this may jeopardize the ability to sit for boards). The time on suspension will be sufficient to satisfactorily complete the delinquent medical records. If the above suspension period occurs, additional education on time management and the importance of record completion may be offered. All suspensions will be for a minimum of 1 day.
If continued delinquencies occur beyond suspension, further action will be at the discretion of the Program Director.
Charts that are not delinquent but are unsatisfactory in terms of quality will be treated in a similar fashion.
July 6, 1999
Amended: February 10, 2000
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