Applies to: WSU Elson S. Floyd College of Medicine Graduate Medical Education (GME) Sponsoring Institution and all accredited post-graduate medical training programs (i.e. residency or fellowship) and non-accredited clinical fellowship programs sponsored by the College of Medicine.
Date: October 18, 2022
1.0 Policy Statement
It is the WSU College of Medicine GME policy that all residents and fellows participating in a college of medicine sponsored graduate medical education training program comply with all medical record policies and procedures at the institutions where they rotate or provide services.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
Accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of importance in graduate medical education.
Trainee
A physician in training at an ACGME accredited graduate medical education program, the term includes Interns, Residents, and Fellows or other trainee enrolled in an educational program whose education falls under the purview of the College of Medicine Office of Graduate Medical Education.
3.0 Responsibilities
GMEC and DIO
4.0 Procedures
Accurate and timely completion of medical records is essential to provide good medical care.
- All Trainees must comply with the applicable health care facility policies where they rotate.
- If a Trainee rotates away from a health care facility, they are still responsible for completion of all charts left at that facility.
- As part of the Physician in Training Agreement, Trainees are expected to keep charts, records and/or reports up to date and signed at all times.
- The formal semi-annual evaluation of a Trainee’s performance must include an element under the competency of Interpersonal and Communication, appropriate utilization and completion of health records.
- All medical record documentation must be current and completed prior to completion of the training program and exiting the college of medicine GME Training Program.
5.0 Related Policies
N/A
6.0 Revision History
GMEC Approval: June 16, 2020
Revision/Review Date(s): October 18, 2022
Responsible Office: WSU College of Medicine Sponsoring Institution
Policy Contact: Designated Institutional Official
Supersedes: N/A