As part of the clinical care provided, it is expected that the resident write a medical record note on each inpatient on every day of hospitalization. A note may not be required each day on Consults, but on any day in which an evaluation is performed a note should be written.
For outpatient visits, a note must be written, typed into an electronic medical record system (where available), or dictated on the same day of service.
All documentation should be completed in a timely fashion in order to facilitate optimal communication among providers. As in private practice, failure to complete dictations (or any documentation) in a timely manner may result in to freezing of educational allowance or suspension from clinical duties. Continuous failure to comply may result in termination.
Medical record documentation is also used for billing purposes. It is the resident’s responsibility (and part of the resident’s education) to learn what documentation is appropriate for each level of service. The Program will ensure that education on billing and regulatory compliance is presented yearly, and will provide pocket cards to the resident for quick reference regarding necessary documentation/billing level of service.
Last reviewed: 5/22/2018, Adam Wallace
