Documentation Policy for Discharge Summaries, Clinic notes, and Duty hours

Updated 2/5/13
Discharge summaries

  1. Inpatient discharge summaries should be completed within 14 days of date of discharge and must be completed by the monthly administrative suspension date,which may fall anywhere between 15-29 days of the date of discharge for a given month (sent in an email to you if you are in danger of administrative suspension).
  2. If you have outstanding inpatient discharge summaries by the day before the monthly administrative suspension date, jeopardy will be used for your rotationuntil you complete all inpatient discharge summaries, all clinic notes, and all duty hour logging and then notify residency administration.
    1. The intern/resident listed in the Discharge order in Epic (or the last resident to attend a patient that expires or transfers to outside institution) is assigned to the discharge summary. This will autopopulate a folder in your Epic inbox called Chart Completion. New records get added manually by medical records daily, so check this folder frequently.
    2. If not completed in the next few days the ‘deficiency’ will show up in a separate Deficiency Letters Folder in your Epic inbox (along with the attending’s Epic inbox) that is tracked by medical records. New records get added manually every Friday.
    3. Every other Friday, medical records will send a Medical Record Completion Notice to house staff, attendings, and department leadership with assigned discharge summaries that will be 15 days or older by the suspension date. The bi-weekly administrative suspension date is in this email. Note that discharge summaries resulting in administrative suspension can range from 15-29 days old.
    4. If records are not completed by the Thursday before their bi-weekly administrative suspension date, the house staff and program administration will be sent a final reminder. If this occurs, the resident must notify the program administration as soon as they have completed the outstanding deficiencies and their name will be checked off.
    5. If the residency program administration has not heard back from the resident on this final reminder list by Monday 7am (the day before suspension), the resident will be pulled from service immediately. They must then complete all discharge summaries, clinic notes, and duty hours. Until they do so and notify the program administration when done, a resident/intern will be jeopardized to their service.
  3. If you are placed on suspension:
    1. You will not be eligible to participate in extra service pay until your dictations are completed and, if you do complete a shift while you have outstanding dictations, payment will be withheld until the dictations are done.
    2. You will lose either ambulatory reading days or elective days (whichever occurs first) until the documents are completed.
    3. All administrative suspensions will be documented in program evaluations.
    4. If you are placed on suspension 3 times in 12 months, your suspension becomes a reportable event to the National Provider Data Bank and may show up when you are applying for a medical license / hospital credentials.

Clinic notes:

  1. Clinic notes should be completed within 2 days of patient visits and must be completed and closed within 7 days of the patient encounter.
  2. If you have a clinic note that has not been completed by 7 days, you will be placed on administrative suspension.

Duty Hours:

  1. Duty hours should be logged daily.
  2. If duty hours have not been documented for 1 month, you will be contacted by program administrators and you will not be eligible for extra service pay shifts until they are completed. If you do complete a shift while your duty hours are greater than 1 month delinquent, payment may be withheld until the dictations are done.
  3. If duty hours have not been documented for 2 months:
    1. You will lose either ambulatory reading days or elective days (whichever occurs first) until the hours are logged.
    2. All administrative suspensions will be documented in program evaluations