A professional approach to record completion

The steady decrease in incomplete and delinquent records has been accomplished without suspending any of the attending physicians. On occasion, hospital administration has, at our request, sent the attending physicians a warning letter alerting them that they will be reported to the Hospital Medical Board if they fail to complete their records. Typical of a teaching facility, the housestaff is primarily responsible for dictation of discharge summaries. They are suspended without pay if they fail to complete their records after being warned. Another significant effect of this program has been the timely entry of ICD-9-CM codes into the billing system within five days of discharge. Accounts outstanding due to lack of final diagnoses and/or attestation statement signatures, ranging from 5-22 days post-discharge, have been reduced to an average of only 40-50 daily. (Vanderbilt University Medical Center averages 22,000 discharges annually). This new program has placed the Medical Record Department in total control of the incomplete/delinquent records. By having less than 300 records to handle, we can provide much better service to the physicians, locate needed records quickly, and maintain an excellent working relationship with the Patient Accounting Department. Medical and hospital administration staff members now regard medical record personnel as organized and effective record managers.