Maintenance and Disclosure of Informaton about Residents and Fellows

These guidelines govern the maintenance by Southern Illinois University School of Medicine (hereinafter called the “School”) of records and disclosure of information about Residents and Fellows (hereinafter called “Residents”) who participate in Residency and Fellowship Programs (hereinafter called “Residency Programs”) operated by the School of Medicine and its affiliated hospitals.

1.  Records of evaluation of a Resident by the School (hereinafter called “Evaluation Records”) required by Section C.1. of the Agreement With Physician (hereinafter called the “Agreement”) shall be stored permanently in the Program Director’s office (subject to the School’s records retention policy). In addition to evaluations of the Resident’s performance, such records may include, without limitation, records of suspension pursuant to Section E. of the Agreement, termination pursuant to Section F. of the Agreement, non-renewal pursuant to Section G. of the Agreement, termination or other discipline pursuant to Sections F. and I. of the Agreement, and any action taken by or against the Resident pursuant to the Due Process and Resident Complaint Policy, but such records shall not include information recorded pursuant to the Impairment Policy of SIU School of Medicine and Affiliated Hospitals for Residency and Fellowship Programs (hereinafter called the “Impairment Policy”), which information shall be maintained only in accordance with paragraph 2. below.

2.  Records about a Resident created pursuant to the Impairment Policy (hereinafter called “Impairment Records”) shall be maintained apart from the Resident’s Evaluation Records and shall be stored in the Program Director’s office as long at the Resident is a participant in the Residency Program. Impairment Records may contain information protected from disclosure by federal and state laws and rules, including, without limitation, the following:

a. The federal Americans With Disabilities Act

b. The federal Health Insurance Portability and Accountability Act

c. Federal regulations at 42 CFR Part 2 prohibiting disclosure of information regarding drug or alcohol dependency

d. The Illinois Medical Patients Rights Act

e. The Illinois AIDS Confidentiality Act

f. The Illinois Mental Health and Developmental Disabilities Confidentiality Act

g. The Illinois Alcoholism and Other Drug Abuse and Dependency Act.

3.  The Resident shall be permitted to review the foregoing records and to receive copies thereof, except when prohibited by law (e.g., Section 3. of the Illinois Mental Health and Developmental Disabilities Act, which requires that that psychological tests be disclosed only to a psychologist designated by the tested individual).

4.  When Impairment Records are no longer needed by the Program Director, they shall be transferred to the Office of Graduate Medical Education for permanent storage (subject to the School’s records retention policy), provided that such transfer shall take place not later than when the Resident completes or otherwise leaves the Residency Program, and no copy of Impairment Records, or any part thereof, shall be maintained elsewhere.

5.  Requests for information about a Resident or former Resident for whom no Impairment Records have been created shall be answered by the Program Director, with the assistance of the Office of Graduate Medical Education, as needed. No information about a Resident shall be disclosed unless the Resident has signed a written authorization for the disclosure.

6.  Requests for information about a Resident or former Resident for whom Impairment Records have been created shall be answered only by the Office of Graduate Medical Education (or by the Program Director with the concurrence of the Office of Graduate Medical Education). No information about a Resident shall be disclosed unless the Resident has signed a written authorization for the disclosure which satisfies the requirements of the appropriate laws and rules, such as those listed in paragraph 2. above.

7.  In certain circumstances the Office of Graduate Medical Education may, in consultation with legal counsel, disclose information about a Resident or former Resident without authorization from the Resident or former Resident if such disclosure is in the public interest.