CM-17 Delinquent Medical Records

DELINQUENT MEDICAL RECORDS

I. SCOPE

This policy applies to all LSUHSC physicians, both faculty and house staff.

II. PURPOSE

The purpose of this memorandum is to reduce the number of delinquent medical records.

III. POLICY

All discharge summaries are to be dictated within ten (10) days of the discharge of a patient, all operative reports are to be dictated immediately following the procedure's completion. All verbal orders, and other physician signatures, including medication reconciliation forms shall be signed within 5 days.

•A list of the delinquent medical records will be compiled by the Medical Records Department and delivered to the appropriate faculty member's office and placed in the appropriate house officer's mailbox on Tuesday morning. Should a holiday fall on Monday, the list will be delivered and/or placed in the mailbox on Wednesday and the physician will have until the following Wednesday to correct any deficiency.
•The physician will have until the following Tuesday morning at 8:00 a.m. to dictate the discharge summaries. If the physician fails to do so, they will be immediately placed on leave without pay until the discharge summary is dictated.
•After the dictation is completed it is the physician's responsibility to notify the Assistant Director of Medical Records at extension 55782 that the discharge summary has been dictated.
•At 6:00 am each day Medical Records will determine which operative reports have not been dictated from the preceding day. Physicians who have un-dictated operative reports will be called and requested to complete the dictation no later than 11:00 am that day.
•The list of delinquent operative reports will be re-examined at noon. If the physician has not dictated by noon the Hospital Administrator will be notified and he/she shall notify the appropriate Department Chairman and the Physician. The Physician will immediately be placed on leave without pay for a minimum of one day or until the appropriate action is taken.
•After the dictation is completed it the physician’s responsibility to notify Manager, Incomplete Charts at extension 54201 or the Assistant Director of Medical Records at extension 55782 that the dictation is complete.
•All verbal orders, operative reports, discharge summaries and medication reconciliation forms shall be signed within 5 days. If a physician is notified of a delinquent signature he/she shall have 7 days to correct the deficiency and failure to do so he/she shall be placed on leave without pay until the deficiency is corrected. If the physician has been placed on leave without pay at any time during the fiscal year, any subsequent failure to sign verbal orders, operative reports, discharge summaries and/or medication reconciliation forms will be treated as second, third and fourth suspensions.
•On the second suspension during any fiscal year, failure to correct the deficient record will cause the physician to be placed on two (2) weeks leave without pay; and if the record is not brought current during that two (2) weeks, the leave without pay will continue until the record is current.
•On a third suspension during any fiscal year, failure to correct the deficient record will cause the physician to be placed on leave without pay for a period of thirty (30) days and will remain on leave without pay until the record is corrected.
•On the fourth suspension during any fiscal year, the non-tenured faculty and house officers will be terminated. Tenured faculty will be disciplined as may be appropriate.
•It is the responsibility of each physician to make certain that his or her records are current before taking annual leave or making a rotation to an off-campus facility. The Medical Records Department will notify by e-mail the Medical Education Department and each clinical chairman of the physicians in their department who have delinquent records. It is the responsibility of the Medical Records Department to notify the Hospital Administrator and the clinical department head of the names of any physician who has not corrected their delinquent medical record within the time prescribed above, and the Hospital Administrator or the administrator on call will notify Human Resource Management to place the individual on leave without pay as may be appropriate.

This memorandum is effective November 15, 2003.

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Signed: John C. McDonald, M.D. Chancellor
Amended April 1, 2007