THE UNIVERSITY OF TENNESSEE
Health Science Center
College of Medicine Chattanooga Office of the Dean 960 East Third Street, Suite 100 Chattanooga, TN 37403 Tel: (423) 778-6024 Fax: (423) 778-3672 www.utcomchatt.org
University of Tennessee College of Medicine Chattanooga Graduate Medical Education Committee Institutional Policies
Quarterly Review of Inpatient and Outpatient Charts for Resident Supervision Documentation
The University of Tennessee College of Medicine Chattanooga (UTCOMC), in cooperation with the Erlanger Medical Staff, requires each program to conduct quarterly audits of both inpatient and outpatient charts involving patient care provided by residents in order to meet Joint Commission for the Accreditation of Health Care Organizations (JCAHO) requirements for documentation of resident supervision. Areas included in the reviews are: • Admission approved by an attending • Invasive procedures approved by an attending • Patient care plan reviewed by an attending at appropriate intervals during hospitalization • Recognized clinically significant changes are promptly reported and reviewed by the attending • Co-signatures are obtained where appropriate • Evidence of attending documentation is clearly identified in the medical record. A minimum of ten inpatient and ten outpatient charts should be utilized in the review. Program directors are encouraged to involve residents in the chart reviews and should discuss any problems identified during resident conferences. Quarterly reports should be sent to the Erlanger Medical Staff Office and copies sent to the Designated Institutional Official (DIO). Samples of the forms developed by the Erlanger Medical Staff are attached to this policy. Reviewed by the GMEC at the November 22, 2005 meeting.