MUSC GME Resident Handbook

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Graduate Medical Education  2013-2014

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Resident Handbook Introduction

Letter of Commitment/
Accreditation Status Disclaimer

Administration & Governance - Graduate Medical Education Programs

Policies & Procedures

Salaries & Benefits

MUSC Policies

Appendix 1 - Resident Agreements (Medical and Dental)

Appendix 2 - Evaluation Forms

Appendix 3 - Forms

Appendix 4 - Scopes of Practice

Appendix 5 - Program Director/Program Coordinator Resources

 

MEDICAL RECORDS
(For More Info See Medical Center Policy A-83)

POLICY

The resident is responsible for the preparation of a complete, legible and current medical record for each patient in compliance with all hospital, state and federal (e.g., CMS - Center for Medicare and Medicaid Services) and HIPAA - Health Insurance Portability and Accountability Act) regulations.  The medical records system documents the course of each patient's illness and care;  is available at all times and is adequate to support quality patient care, education of residents, quality assurance activities and scholarly work.

PROCEDURES

  1. After a patient is discharged and all essential reports are received and placed on the medical record, the resident shall complete the medical record within fifteen (15) days after resident assignment. If a medical record is not completed and returned within twenty (20) days after resident assignment (5 days in arrears), the resident and the Residency Program Director will be notified. If the medical record is not completed and returned within twenty-five (25) days after resident assignment (10 days in arrears), the resident and the Residency Program Director will be notified again. At this point, disciplinary action may be taken against the resident.

    Each department shall establish a policy describing the role of the residents and attendings with regard to dictating and signing discharge summaries.

  2. Any resident who cannot complete his/her medical records (due to vacation,long-term illness or educational leave) must notify Health Information Services at 792-3881.

  3. The medical record shall be considered delinquent in the second and fourth Thursdays of each month at 8:00 am. On these days, the Medical Director for Professional Staff will issue a list of those residents with delinquent medical record.

  4. The Medical Director for Professional Staff will notify the appropriate Residency Director of the resident(s) with delinquent medical records. If the resident makes an attempt to complete the chart(s) but the chart(s) cannot be located, the resident or attending must notify the Residency Director, who must notify the Medical Director for Professional Staff.

  5. Privileges for clinical training purposes (e.g. treating patients) may be suspended or other actions may be taken in accordance with department policy.  Reinstatement of privileges for clinical training purposes may be accomplished upon completion of the delinquent records.

  6. A resident on the delinquent list three (3) times during a twelve (12) month period will be suspended from the residency program and must submit a written justification for these delinquencies to the appropriate Residency Program Director and the Designated Institutional Official for GME.

  7. A resident on the delinquent list six (6) times during a twelve (12) month periodmay be dismissed from the residency program at the discretion of the Residency Program Director and terminated by the Designated Institutional Official for GME.

  8. It is the responsibility of the resident to notify Health Information Services upon completion of any delinquent charts.medical records by a resident will be considered unprofessional behavior and handled as an academic matter and will result in disciplinary action toward the resident.

  9. Any removal of patient medical records from the appropriate hospital locations and/or improper handling of patient medical records by a resident will be considered unprofessional behavior and handled as an academic matter and will result in disciplinary action toward the resident