IM_P&P_Medical Records

	INTERNAL MEDICINE POLICIES & PROCEDURES Internal Medicine Education Policy For Completion of Medical Records At Texas Health Presbyterian Hospital Dallas	Policy Number : 13
		Date Issued : 11/2002
		Prior Revision Date : 01/2003
		Date Revised : 08/2009

PURPOSE

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

SCOPE

Applies to all interns and residents (hereafter all will be referred to as trainees) in the Internal Medicine training program on the Texas Health Presbyterian Hospital Dallas campus.

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 fram 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

GME Policy. Medical Records “Health Information Management; Department of Information” Packet


	MARK FELDMAN, M.D. Chairman, Internal Medicine Program Director, Internal Medicine	BRUCE BOUGENO Vice President, Medical Staff Affairs