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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Centralized Monitoring of Delinquent Medical Records
Policy Number: 6.17
Effective Date: August 23, 2017
Chapter: Health Information Management
To ensure the hospital-wide inpatient/observation delinquent record rate is under 50%, in compliance with
the UW Health Administrative Policies.
A. A delinquent record is defined as a hospital encounter which is missing any of the following
elements more than fourteen days post discharge: (per UW Health Administrative
Policy 6.15-UW Health Medical Record Documentation).
1. Documented and signed discharge summary
2. Documented and signed operative/procedure note (when applicable)
3. Documented and signed history and physical
B. Clinician Author: A clinical staff member who has the authority and responsibility for creating
and/or authenticating patient health record entries. Examples include: Physicians, Advance
Practice Nurses, Certified Nurse Midwives, Physician Assistants, Psychologists, Pharmacists,
Speech Language Pathologists, Audiologists, Licensed Clinical Social Workers, and any other
health care professional licensed, credentialed, and/or approved by UW Health to document in the
patient health record. Clinician Author also includes residents and students in approved health
occupation programs under the supervision of a clinical staff member.
III. POLICY ELEMENTS
All inpatient and observation health care records will be completed within fourteen days post discharge. It
is strongly encouraged that the inpatient medical record be completed within 7 days (see UW Health
Administrative Policy 6.15-UW Health medical Record Documentation).
A. To facilitate an acceptable level of compliance, clinician authors are provided multiple
notifications regarding outstanding medical record documentation.
1. A report is e-mailed to all attending physicians weekly from Document Integrity.
2. Health Link In-Basket notification to the clinician author at creation of the deficiency
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3. Additional reports created at the department level.
B. Health Information Management performs daily reviews of all of the above listed medical record
deficiencies (See II.A.1-3) and coordinates completion with clinician authors as needed.
C. The Medical Record Committee is provided a semiannual report summarizing the breakdown of
delinquent records by date range. More frequent reports will be provided as needed or requested.
D. The Department Chairs, section heads, or designated department administrators receive weekly
notification of their clinician authors’ incomplete documentation exceeding 14 days post-discharge.
E. The CMO and Director of Coding/CDI receives weekly notification of all clinician authors’
incomplete documentation exceeding 30 days post-discharge.
F. Additional detailed reports are provided as requested.
Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management
Reviewer: Medical Record Committee
Approval Committee(s): UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer