Ask the expert: What are the documentation retention guidelines?

Residency Program Insider, August 2, 2010

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Discarding the wrong items can cause legal troubles for programs. Certain documents are used to verify graduates’ training, whether that’s now or in 50 years.

Consider adapting the following language for your own documentation retention guidelines or policies:

  • Each GME program will maintain a program file for each resident and fellow. The file will contain a record of the resident’s specific rotations and other educational experiences (including procedural logs), evaluations, periodic summative reviews, any disciplinary actions, the final evaluation by the program director, and other information concerning the resident that the program director judges appropriate to maintain in the file for educational and/or credentialing purposes.
  • The resident’s program file will be treated as a confidential document. Files will be maintained in a secure location and will be available only to the program director, the GME director, the program’s evaluation committee, designated staff members, and the resident. The resident’s access to his or her file should be under direct supervision of a designated staff member of the program or the medical education department.
  • The program director may disclose the program file, or portions thereof, to others judged to have a legitimate need for the information, for reasons relating to the accreditation of the program or of the program’s participating institutions. The program director may also disclose the file, or portions thereof, to others, as authorized in writing by the resident.

The above excerpt originally appeared in the January issue of Residency Program Alert’sResident file contents: Destroy, hold, or keep.”

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