/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/uwhc-wide/,/policies/administrative/uwhc/uwhc-wide/medical-records/,

/policies/administrative/uwhc/uwhc-wide/medical-records/636.policy

201510274

page

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UWHC,

Policies,Administrative,UWHC,UWHC-wide,Medical Records

Record Completion for Staff on Leave or No Longer Practicing (6.36)

Record Completion for Staff on Leave or No Longer Practicing (6.36) - Policies, Administrative, UWHC, UWHC-wide, Medical Records

6.36

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Administrative (Non-Clinical) Policy
Category:
 UWHC only (Hospital Administrative-entity wide)  UWMF only (entity wide)
 UWHC Departmental (indicate name)  UWMF Departmental (indicate name)
 UWHC and UWMF (shared)
Policy Title: Record Completion for Staff on Leave or No Longer Practicing
Policy Number: 6.36
Effective Date: October 1, 2015
Chapter: Medical Records
Version: Revision
I. PURPOSE
A. To establish guidelines for the completion of records by clinician authors with dictation and
Health Link privileges who are leaving permanently, are deceased, or going on extended leave
greater than 30 days.
B. To establish guidelines for the filing of incomplete records.
II. POLICY

The attending physician shall be responsible for the preparation of a current, complete and legible medical
record. The Department Chair shall be administratively responsible for seeing that physicians within their
respective department complete documentation in accordance with standards adopted by the Medical
Board (refer to Administrative policy 6.15-Medical Record Documentation Policy).

No medical staff member is permitted to complete documentation on a patient unfamiliar to him/her in
order to retire a document that was the responsibility of another staff member who is deceased,
unavailable permanently or protractedly for other reasons.

All clinician authors are responsible for completion of their documentation. Health Information
Management (HIM) monitors the dictation/transcription system and Health Link and notifies users of all
incomplete documentation.

III. DEFINITIONS

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’s 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. It is also recognized that others besides Clinician Authors may assist in the
documentation process, but they do not have final responsibility for the documentation; this responsibility
is assigned to the author who finalizes or authenticates the patient health record entry.


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Attending physician: The physician who has been selected by or assigned to the patient and has assumed
primary responsibility for the treatment and care of the patient.

III. PROCEDURE
A. Medical Staff
1. Any medical staff member with documentation privileges who anticipates leaving
permanently or protractedly, will notify the Medical Staff Office or appropriate
department leadership and Health Information Management (Record Quality -
himreqqual@uwhealth.org ) as soon as it is known, and at least two weeks in advance
where possible.
a. Record Quality Supervisor will communicate with the Transcription Manager
who will independently coordinate electronic authentication of all transcribed
reports before their last working day.
b. HIM staff will review the InBasket of the staff member and contact him/her
asking that they complete any outstanding InBasket messages and incomplete
documentation before their last working day.
c. Department Chairs will be contacted to assist in the review of clinical messages,
within the Inbasket, for users who are no longer practicing.
2. Medical Staff will be responsible for ensuring that all documentation is completed within
Health Link, to include the following InBasket folders:
a. Chart Co-sign
b. Co-sign Notes
c. Co-sign Clinic Orders
d. Hospital Chart Completion
e. Incomplete Chart
f. My Open Encounters
g. Open Anesthesia Records
h. Transcription
B. All Other Clinician Authors
1. All other clinician authors are responsible for completion of documentation prior to
his/her last day of employment. All electronic record access is removed after that
clinician author’s last day of employment.
C. In the case of a protracted leave, any document that remains incomplete will be filed as such
using an electronic templated Statement of Completion (Health Link and transcribed documents).
A list of these documents will be maintained in Health Information Management and the
documents will be directed to the responsible clinician author for completion when he/she returns.
1. In the event a clinician author has expired, the medical record will be filed as complete
using an electronic templated Statement of Completion (Health Link and transcribed
documents). Health Information Management staff will maintain a log of all medical
records filed/administratively closed as "complete" using the process outlined above.
2. Electronic Templated Statement of Completion
“Under Circumstances of (clinician author is on extended leave [greater than 30 days],
clinician author has permanently left practice at UWHC, clinician author has expired),
this record has been declared complete for filing purposes. It is considered to be a
complete medical record for purposes of University of Wisconsin Hospital and Clinics
business. The incomplete record components include (document type, date and missing
elements)”
3. This statement of completion will be signed using the .me2 phrase in HL.

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IV. COORDINATION

Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management

Review/approval Committee(s): Medical Record Committee, Administrative Policy & Procedure
Committee, Medical Board

SIGNED BY

Ronald Sliwinski
President, University of Wisconsin Hospitals
Chief of Clinical Operations



Revision Detail:

Previous revision: September 2012
Next revision: October 2018