Resident File Standards

I.    Scope

This standard was developed for SIU Medicine. SIU Medicine collectively applies to the SIU School of Medicine (SIU SOM), including the Federally Qualified Health Center (FQHC), and SIU HealthCare (SIU HC). These entities are collectively referred to as SIU in this document.

This document applies to SIU staff, faculty, trainees, agents, officers, directors, interns, volunteers, contractors, and any other individual or entity engaged in providing teaching, research and health care items and services at SIU. These individuals are collectively referred to as SIU personnel in this document.

II.    Definitions 

The term “resident” is inclusive of all trainees at SIU SOM, whether training in a residency or fellowship program.  The term “program” is inclusive of all SIU residency or fellowship programs, whether accredited or non-accredited.

III.    Purpose

To establish requirements for content of an official resident file, managed by the training program.

IV.    Procedure

The ACGME and institution have guidelines for the required minimum content kept in the official resident file by the residency program office.  The content can be kept in paper format, electronic format, or a combination of both.  Many of the evaluations, time records, and demographic information will be contained in New Innovations (NI) or other electronic applications.  No matter the format, resident files must be kept in a secure location.  Electronic documentation must have file back-up and recovery protocols that are consistently followed.

Any documentation regarding impairment must be kept in a separate secured file in the program director’s office.  

During a site visit, the ACGME will review a selection of resident files.  Site visitors might request different variations of resident files to review, however it is recommended that the program be prepared to produce current resident files per PGY of training, a selection of files from the most recent graduates, and any transfer (in or out) resident file from the three most recent academic years.  Programs can be cited for incomplete files. Evaluations that are kept in NI or another electronic application, must be able to be reproduced upon request (i.e. saved on a flash drive, printed, or guided access).

Residents are able to view their file in the presence of a residency program representative.  Refer to the following document for additional information: Standards for Maintenance of Records and Disclosure of Information about Residents and Fellows.

V. File Elements

1. Applications
   1. ERAS application or other application when ERAS is not applicable
   2. Transfer Resident: Copies of evaluations, final summative evaluation from the Program Director, transferring resident form, and milestone evaluations
   3. Personal Information Documentation
2. Contracts / Work Authorization
   1. Signed letter of offer
   2. Signed contracts and contract renewal letters for each year of training
   3. Medical school graduation documentation
   4. ECFMG Certificate – International Medical Graduates only
   5. Visa information and/or work authorization documentation - if applicable
   6. GME certificate(s) for previous training – if applicable
3. License
   1. License documentation & verification
   2. Federal DEA license – if applicable
   3. Moonlighting approval (Program Director letter and Institutional) – if applicable
4. Certifications / Credentials
   1. BLS, ACLS, ATLS, PALS, NRP, etc.
   2. Verification of enrollment: NPI, IMPACT, PECOS
   3. USMLE/COMLEX score transcripts
5. Required Training
   1. Specialty specific required training verification
   2. Institutional required training verification
6. In-service / In-training Exams

7. Evaluation Documentation

   Evaluations can be paper, electronic print outs, or accessible online. Must include 
   evidence of resident review.  When evaluations are requested as part of a resident file for due process proceedings or legal review, individual evaluations must be provided versus a summary.

   1. Rotation and other Evaluations
   2. 360° Evaluations by the faculty, nurses, patients, students, peers, others, or self-evaluation
   3. Periodic performance evaluation / CCC assessments (at least semi-annual) and documentation that this was discussed with the resident– NOTE: Do not include CCC minutes in the resident file. The assessment in the file should be a separate document that is provided to the resident with CCC feedback.  PD and resident signatures acknowledging review of the information are recommended.
   4. Faculty Advisor documentation
   5. Milestones Assessments
   6. Procedural Autonomy Assessments
   7. Summative Evaluations / readiness to promote
   8. Final Summative Evaluation, including readiness for autonomous practice (required for every exited resident)
8. Rotation Information / Goals & Objectives
   1. Documentation verifying the residents received the goals & objectives
   2. Away rotation paperwork, if applicable
   3. Case Logs
   4. Record of the resident’s rotations and other training experiences as applicable
9. Leave Time Documentation (time away from program)
   1. If resident takes PCML, must include:
      1. Documentation that PD discussed with the resident the potential impact of PCML on length of training
      2. Written notification if such absence necessitates extension of training in order to fulfill the requirements of the Residency Program and specialty Board.
      3. Any documentation containing confidential medical information/PHI should be kept in a separate, secured location and not disclosed without written consent.
10. Scholarly Activity / Quality Improvement
    1. Information about resident presentations, abstracts, publications
    2. Information regarding any quality improvement projects
11. Post Residency / Verifications
12. Deficiencies / Discipline Matters
    1. Documentation of performance / academic problems (including Program Letters of Concern or other performance improvement plans
    2. Letters of Deficiency
    3. Termination or Non-renewal of Contract Letters
    4. Documentation regarding disciplinary action or suspension if applicable
    5. Complaints / investigations (including Patient Safety or Professional Conduct reports from clinical sites, critical incidents, etc.)
    6. Correspondence specific to resident performance concerns, critical incidents or investigations thereof.  (Anything kept in this section should be considered part of the resident’s file and viewable by resident. PD should discuss with resident before adding to file.)
    7. IDFPR Medical Mandatory Report (MMR) form and any corresponding documents regarding a separation as described on the MMR form instructions.
13. Miscellaneous
    1. Photos - if applicable
    2. Other documentation (required trainings, QIPS activities, etc.)
    3. Awards, accolades, commendations
    4. Portfolio items, if applicable

VI.    References

VII.    Attachments 

Attachment A: Elements of a Resident Due Process File (See Below)

Attachment A

Elements of a Resident Due Process File

• See Resident File Standards for details of each Section
• These elements of the resident’s file are included in a Due Process File
  • Section 1    Applications
    • If this section is requested, only LORs in which the resident did NOT waive their right to view the letter will be included)
  • Section 3    License
  • Section 9    Leave Time Documentation
  • Section 11    Post residency / Verifications
• These elements of the resident’s file are not included in a Due Process File – May be submitted upon request of resident or PD
  • Section 2    Most recent resident contract and all contract renewal letters      
  • Section 4    Certification and credentials- ALL
  • Section 5    Required training- ALL
  • Section 6    In-service / In-training Exams- ALL
  • Section 7    Evaluation Documentation -ALL
  • Section 8    Rotation Information / Goals & Objectives - ALL
  • Section 10    Scholarly Activity / QI - ALL
  • Section 12    Deficiencies / Discipline Matters - ALL
  • Section 13    Miscellaneous