As part of the clinical care provided, it is expected that the fellow write a medical record note on each inpatient on every day of hospitalization. A note may not be required each day on patients for whom we are providing consultative services, 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 the 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 fellow’s responsibility (and part of the fellow’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 fellow for quick reference regarding necessary documentation/billing level of service.
Fellows have ready access to specialty-specific and other appropriate reference material in print or electronic format, and electronic medical literature databases with search capabilities are available at the Ebling health library adjacent to the UWHC and VAH. The Ebling library is open during normal business hours, but the vast majority of its information is available 24/7 online through a UW login. The Program Coordinator is available for assistance on accessing these resources.
Latest revision: 07/13/2020
Luke Bradbury, MD