Trainee Record Retention Policy

I. Purpose of policy

To delineate the way in which Accreditation Council for Graduate Medical Education (ACGME)-accredited Graduate Medical Education (GME) programs will maintain Resident and Applicant records at Dartmouth-Hitchcock (D-H).

II. Policy scope

This policy applies to Program Directors, Program Coordinators and GME Office staff at D-H.

III. Definitions

Applicant: Any eligible Medical Doctor (MD) or Doctor of Osteopathy (DO) applying for acceptance to a GME program.

COMLEX: Comprehensive Osteopathic Medical Licensing Exam.

ECFMG: Education Commission for Foreign Medical Graduates.

Electronic Residency Application Service (ERAS): The centralized online application service used by the Association of American Medical College (AAMC) to transmit residency applications to Program Directors.

GME Files: Personnel files external to MedHub which reside in the GME Office network files or in paper files.

Life Support Certifications: Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS), Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP).

Program: Program Director and Program Coordinator.

Program Files: Materials other than those personnel files in MedHub which may reside in department network files.

Medical Student Performance Evaluation (MSPE): Also known as the Dean’s Letter, the MPSE in a medical school evaluation that the Resident applicant has waived the right to see that is received as a part of the Resident’s application.

Resident: Any physician in an accredited GME program, including Residents and Fellows.

Resident Graduate: A Resident who successfully graduates from an ACGME-accredited training program at D-H.

Resident Non-Graduate: A Resident who does not successfully graduate from an ACGME-accredited training program at D-H. Resident Non-Graduates include Residents dismissed pursuant to disciplinary action, those whom transfer to an external training program, and those who term for other reasons without graduating.

Resident Records: Electronic records pertaining to a Resident’s training. Resident Records include:

  1. Personnel Records – confidential records containing factual, objective, and employment-related information and;
  2. Quality Assurance (QA) records – confidential documents pertaining to the evaluation of Residents that are protected from disclosure under New Hampshire State Law (RSA 151:13-a and RSA 329-29-a) and Vermont Law (26 V.S.A. § 1441, 26 V.S.A. § 1442 and 26 VSA § 1443).

Scholarly Activity: An opportunity for Residents and faculty to participate in research, as well as organized clinical discussion, rounds, journal clubs, and conferences (e.g. presentations and attendance at national meetings, research projects, publications).

USMLE: United States Medical Licensing Examination.

 

IV. Policy statement

  1. General
    • Resident Records provide a comprehensive record of trainee activities in a GME training program. Resident Records are learner records, employee records, and are used to verify completion of training requirements.
    • GME programs must maintain Resident Records in the Residency Management System, MedHub. Additional files may be kept in department network files. Archived files for Residents that graduated prior to 2015 may be kept in paper format at a D-H approved off-site location.
    • Resident case/procedure logs must be de-identified of any Protected Health Information (PHI) (e.g. patient names and medical record numbers).
       
  2. Resident Record Access
    1. GME and Program Access: Resident Records are available to the Program, Program Faculty (Interview Committee and Clinical Competency Committee), and to GME (Administrative Director, Designated Institutional Official (DIO) and office staff) as indicated in section D below.
    2. Current Resident Access: Upon request, the Resident may receive a copy of and/or will receive timely access to review his or her Resident Records under the direct supervision of the Program Director or Program Coordinator, with the exception of:
      • Items the Resident has waived the right to review, and;
      • QA documents or any other information which is privileged, confidential, proprietary, or otherwise legally protected under federal or New Hampshire law.
    3. Disclosure to Others: The Program Director, DIO, GME Administrative Director or designee may disclose the Resident Record or portions thereof, to individuals with a business need for the information (e.g. for matters relating to the education in the program, or the quality of patient care in the program).
      • The Program Director, DIO, Administrative Director or designee may also disclose the Resident Record, or portions of the Resident Record, to a hospital or other health care facility upon request in connection with credentialing/privileging activity as authorized in writing by the Resident, Resident Graduate, or Resident Non-Graduate, and as documented with a completed D-H Authorization and Release of Liability form.
      • D-H Risk Management and the Office of General Counsel must review all documents considered to be QA documents prior to being provided to individuals external to Dartmouth-Hitchcock, including Resident Graduates and Resident Non-Graduates.
      • The Office of General Counsel will be available to assist with all questions relating to whether certain documents may or may not be disclosed to external parties.
  3. Record Retention
    Records may not be destroyed if any litigation, claim, negotiation, audit, open records request, administrative review, or other action involving the record is initiated before the expiration of a retention period for the record until the completion of the action and the resolution of all issues that arise from it.
    1. Resident Records: Programs are required to retain Resident Records for a minimum of seven years after completion of training or withdrawal from the program, unless otherwise noted below. In addition, programs must follow record retention guidelines set by the program’s ACGME Review Committee (RC), if any.
      • Resident Non-Graduate - Entire record must be permanently retained.
      • Resident Graduate - The following items must be permanently retained:
        • Rotation/Training: Dates of training, graduation certificate, VGMET form, procedure/operative logs, rotation/on-call schedules*
        • Evaluation: Final summative evaluation
        • Confidential Items: Board scores, verifications of training, grievance and appeals materials, notice of termination, disciplinary actions
        • Incoming Transfer Resident verification of previous educational experience, summative evaluation
      *Resident rotation/on-call schedules must be retained for 10 years following the end of the fiscal year, in order to provide primary verification of rotations in the event of a Medicare audit of prior training years.
    2. Records of Unsuccessful Applicants: Records of Applicants who did not match, were not accepted, withdrew from consideration, or were not interviewed will be retained by the program for two years after recruitment has ended and final candidates have matched/accepted for the academic year being filled.
      • ERAS Users: ERAS automatically maintains application records in an archive accessible through the ERAS website. No additional retention of application materials is necessary.
      • Other Application Processes: Programs are responsible for maintaining application records in paper or department network drives.

       
  4. Resident Records to Keep During Training
Records Can purge
7 years post-grad.		 Access
Permitted		 Record
Location		 Maintenance
Responsibility
Application
ERAS/equivalent application form Yes Resident
Faculty Program
GME		 MedHub Program
  Curriculum vitae
  Personal statement
  Medical school transcript
  USMLE/COMLEX transcripts
  ECFMG, visa/immigration
  MSPE (confidential material) Program
GME
  Letters of recommendation
  (confidential material)
Interviewer evaluation forms Program Files
Applicant/program director correspondence
Transfer Resident (incoming)
Verification of previous educational experience No Resident Program
GME		 MedHub Program
Summative evaluation
General Personnel Information
Demographics Yes Resident
Program
GME		 MedHub Program/GME
Contracts GME
NH training license
Lab coat information
Leave of absence
Request for vacation time
I-9 files (or other disclosing ethnicity, national origin or citizenship) No GME Files
License application/renewals Program
Background checks GME MedHub GME
Rotation/Training
Graduation certificate No Resident Program GME MedHub GME
VGMET form Program
Dates of training
Rotation/on-call schedules
Procedure and/or operative logs (if applicable)
Conference attendance logs/dates Yes
Life Support Certifications (BLS/ACLS etc.)
Scholarly activity MedHub or Program Files
Moonlighting MedHub GME
Evaluations
Formative evaluations Yes Resident Program GME MedHub Program
Semi-annual evaluations
Final summative evaluation No
Other
Correspondence Yes Resident Program GME MedHub or Program Files Program
Awards
Confidential – Resident Access
Promotion recommendations Yes Resident Program GME MedHub Program
In Training Exam (ITE) results
Board scores No
Verifications of training
Grievance and appeals materials Resident Program GME GME
Notice of termination
Disciplinary actions
Confidential – No Resident Access
Application Process
MSPE (Dean’s letter) Yes Program GME MedHub Program
Faculty letters of recommendation
Other letters of recommendation

D-H Policy ID: 17336