VII. Medical Record Keeping

Medical Record-Keeping

Definition

SUBJECT: MEDICAL RECORD-KEEPING Updated August 10, 2011

PURPOSE: To inculcate in trainees the importance and process of appropriate and timely medical record documentation and completion.

SCOPE: All trainees in Neurological Surgery at all institutions.

POLICY:
All trainees are expected to ensure that the following criteria is followed for appropriate documentation of patient care activities:
1) All notes and orders are dated and timed.
2) All notes and signatures are legible.
3) All notes and orders written by medical students are co-signed by a resident physician or attending physician.
4) All patients admitted to an in-patient service will have a history and physical performed and recorded by a resident physician within twenty-four (24) hours of admission.
5) A preoperative note will be written by the resident physician who intends to participate in the operation noting the patient's condition or problem, the pertinent preoperative evaluation and the planned operative procedure.
6) A brief handwritten operative report will be completed in the medical record indicating the following:
a) preoperative diagnosis
b) postoperative diagnosis
c) operation performed
d) attending surgeon
e) resident surgeon(s)
f) anesthetic used
g) estimated blood loss
h) parenteral fluids administered
i) urine output
j) drains placed
k) specimens obtained
l) apparent complication
7) The resident physician participating in the operation will personally document postoperative visits for inpatients during the immediate postoperative period.
8) Each patient will have a daily progress note, completed in SOAP format, recorded in the medical record noting the patient's current status requiring hospitalization, pertinent physical findings, and any active intervention being provided.
9) All procedures will be documented by a procedure note containing the following information:
a) indication for procedure
b) obtaining of informed consent
c) procedure preformed
d) proceduralist
e) supervising resident or attending physician
f) anesthetic used
g) apparent complications
10) Any significant event occurring in the course of a patient's care will be documented. This includes the following situations:
a) confusion or delirium resulting in the need for physical restraint or chemical sedation
b) deterioration in a patient's clinical condition
c) the need to escalate the level of intervention or care for a patient
d) any belligerent, threatening, or hostile actions, either physical or verbal, on the part of the patient, or any of the patient's family members.
11) A discharge summary will be completed for all inpatients at the time of discharge from the hospital.

Completion of the Medical Record:
All trainees are expected to complete medical records in an accurate and timely manner.
1) UCLA Medical Center: policy regarding delinquent medical records is established by the Medical Staff ByLaws. "All individuals with clinical privileges (Medical Staff and House Staff) are required to complete discharge summaries in a timely manner. Clinical privileges of Medical Staff members and House Officers who have 3 discharge summaries delinquent more than 14 days, (when the chart is available) or 1 discharge summary delinquent more than 30 days shall be immediately suspended and clinical privileges (admitting, consulting, and surgical) rescinded; this shall include charts without signatures. The suspension will be in force until such time as the delinquent medical records are completed."
2) West Los Angeles VA Medical Center: medical records delinquent for greater than fourteen (14) days when the chart is available, will be reported to the Program Director for action.
3) Santa Monica UCLA Medical Center: Residents must sign off with the attending in charge, presumably Dr. Holly, with a statement from the UCLA-SMH medical records office that all of their dictations are completed and signed before they go on to their next rotation.

Failure to complete medical records will result in the following actions, in sequence:
1) Verbal notification and opportunity to complete the records within 72 hours.
2) Formal letter of reprimand for failure to complete medical records to be placed in the trainee's file.
3) Suspension of clinical privileges, including admitting, consulting, and surgical privileges. Such suspension will result in removal from the clinical rotation, and assignment of leave without pay status until such time as the Program Director is notified that the delinquency has been removed. No credit for residency training will be given for the period of suspension. In the event that your clinical privileges are suspended by the date named in your written notification, the following actions are mandated by UCLA Medical Staff ByLaws, and California State Law. Notification of your specialty Certification Board for failure to comply with Medical Center and Medical Staff Rules and Regulations and notification of the Medical Board of California, which may jeopardize the ability to obtain or maintain medical licensure in the State of California.
4) Three (3) episodes of suspension of clinical privileges may result in dismissal from the program.

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