Procedure for Resident File Contents and Retention

Applies to:  All Elson S. Floyd Washington State University College of Medicine GME Programs.

Key Words: file, record retention, access, MedHub, New Innovations

Responsible: Residency Program Director, Program Administrator, Program Coordinator

Purpose

This procedure provides guidelines on what information should be maintained within the electronic resident file, duration that materials will be maintained, and which individuals may have view access to the file.

Procedure

Documentation of a complete training record for each resident is essential for compliance and allows for an efficient monitoring of the resident’s progress.  A complete residency file is also critical for verification of residency post-completion by employers and any future residency programs or fellowships.

1. All content for the resident file must be maintained in a digital format and stored in the residency management system (MedHub or New Innovations).  No paper records should be kept.
2. The program administrator or coordinator for the residency program is responsible for the uploading and maintenance of individual resident files. This includes involvement and support from faculty and program leadership to provide accurate and timely documentation and materials if needed.
3. The electronic resident file should be updated regularly with changes made within 10 business of receipt.
4. GME Office staff will conduct periodic audits of residency files to ensure accurate and timely record keeping.
5. While the resident is active in the residency training program, all required elements identified in Appendix A must be kept and maintained in the resident’s individual electronic file in the resident management system (MedHub, New innovations).
6. Following completion of residency, the items listed in Appendix B will become part of the residents archived file and will be kept indefinitely. 
   • If a resident leaves the program before completion, all elements of the resident file must be archived and kept.
   • A combined pdf file of all the required archived materials should be created and uploaded into the residency management system for easy reference.  
   • A copy of the archived resident file must be sent to the GME contact for the Human Resources Department.
7. Upon completion or departure of the residency program, the individual resident file must be reviewed for completeness within 30 days and materials must be either archived or removed from the system.

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Appendix A

Items of the Resident File to be Retained During Residency

1. Demographic information including contact info, birth date, social security number, IRIS required elements, NPI, DEA, license
2. ERAS Application including CV (f transfer include CV, previous program summative evaluation, USMLE/COMPLEX transcript, ITE scores, letter from PD)
3. Information received from previous program (transfer residents)
4. Medical school diploma
5. ECFMG certificate (if applicable)
6. Visa information – DS 2019, I-94, Visa(if applicable)
7. Pre-employment drug screen and background check information
8. Clinical site compliance elements and training
9. Orientation records
10. Mask fitting documentation
11. MAT training (if applicable)
12. Evaluations (all), 6-month summative evaluations
13. Resident’s rotation schedule
14. Documentation for clinical experiences – procedure logs, case logs, etc.. as required by the specialty
15. Documentation of disciplinary actions
16. Individualized Learning Plan (ILP)
17. Completed onboarding items
18. Attendance records including (PTA, leave, didactic attendance, etc.)
19. Resident Contracts
20. Life support training certifications – BLS/ACLS/other
21. Patient evaluations and feedback
22. Letters of recognition and awards
23. Moonlighting permission
24. Record of scholarly activity
25. In-training exam results
26. Notes, emails, and correspondence related to resident’s progress and performance
27. Off-boarding documentation and checklist

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Appendix B

Items to be Archived Following Residency Training Period

Materials in the listed table are materials that are maintained for individual residents in their archived file post-residency. Materials may be archived following WSU or ACGME policies. Documents and items that were listed in EXHIBIT A but are not found in EXHIBIT B will not be maintained or accessible post-residency or completion.

Item	Location
ERAS Application	Residency management system
Medical School Diploma	Residency management system
ECFMG Certificate (if applicable)	Residency management system
Contracts (Physician in Training Agreement)	Residency management system
Final Summative Evaluation	Residency management system
All Semi-Annual Evaluations	Residency management system
Residency Completion Certificate	Residency management system
Documentation for clinical experiences – procedure logs, case logs, etc.. as required by the specialty	Residency management system
Rotation Block Schedule	Residency management system
Corrective action documentation resulting in disciplinary action	Residency management system WSU Human Resources (if applicable)
Post-Residency Contact Information	Residency management system WSU Workday (if applicable)
Verification of Training Form	Residency management system – Accessible by request from employers, future training programs, etc.