How to fill residents’ files

Residency Program Insider, February 13, 2006

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How to fill residents' files

Dear residency program colleague:

It is important to familiarize yourself with the details of your policy regarding access to residents' files. If your organization does not have a policy that details who is allowed to review files, lead the effort to develop such a guideline. However, don't attempt to draft the policy on your own. Work with your human resources (HR), management, and legal teams to work out the details of the policy.

These experts can likely provide invaluable guidance in regard to file retention and presentation. In addition, their feedback is important when detailing the information that the residents' prospective employers and state licensing board can review.

In general, your policy should grant the program director, the resident, the resident advisor, and the residency performance committee access to residents' files.

The following information is often kept in residents' files:

Decide who will provide information for future queries from state licensing boards, hospitals' credentials committees, and future employers. Your institution's GME office may want to provide some or most of the information with program specific information provided only when necessary. Understand what "releases" you will need from trainees to release information in the future, and how your institution and program might coordinate these requests to make certain information is provided in a timely fashion and in observance with institutional policies.

I recommend not including in residents' files illness-specific medical data, such as documenting that a resident was out because he or she was sick with diabetes. You should also avoid including information regarding a resident's "leave" time, such as FMLA, the dates that the resident was out, and the dates he or she returned. Remember, once the details of your policy are worked out, it is your job to ensure that you and your staff follow the policy.

All the best,

Kathryn Andolsek, MD, MPH

Associate director of GME
Duke University Hospital
Durham, NC

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