Institutional Policy for Record Retention for Graduate Medical Education

PREAMBLE 

Resident/Medical Student documentation is one of the most important aspects of graduate and post-graduate education. Record retention is vital in documenting the specific curricular components for each individual resident and the evaluation of performance, educational needs, and assessment of progress over time (AHME). The ACGME does not have standards for document retention, which specify the period for which records need to be kept after a resident’s graduation. It defers to institutional document retention standards (ACGME Bulletin, August 2008).  In order for programs to determine which documents to retain and which to destroy, the GME office has prepared the following Institutional Policy for Record Retention for Graduate Medical Education.

POLICY

The GME office has determined that the following core files should be kept indefinitely for residents recommended for Board certification:

• A summation of the resident’s evaluations (final evaluation) and/or the final letter by the Program Director
• Records of dates of training, trainee’s rotations, training experience, and procedures
• Records of disciplinary actions
• Materials required by the ACGME/RRC
• Other records judged important by the Program Director

For residents that have completed the program and are recommended for Board certification, the following files may be destroyed after 6 years:

• Rotational evaluations
• Letters of recommendation
• Annual/Semi-Annual Self Evaluations
• Resident Data Sheet
• License information (MBC and DEA)
• ERAS application
• Curriculum Vitae
• ECFMG Certificate

For residents who do not complete the program or who are not recommended for Board certification, the entire file should be maintained as a permanent record for at least six years (longest statute of limitations for legal challenge by affected resident) (AHME).

Medical Students

In order to obtain medical licensure in the State of California, the Medical Board of California requires documentation of all medical student clerkship rotations. In order to facilitate this requirement, the GME office mandates that programs maintain files of all medical student clerkship rotations for at least 6 years.  These files must include:

• Student Rosters with names and dates of rotating students

• All Student Evaluations 

• Student Rotation Schedules

Special consideration

Discretion over records about referral for psychiatric evaluations, drug counseling, or health problems must be observed by the Program Director. If the consultation is important to the educational process of the resident, then it should be included in the file. If the condition is successfully resolved during residency, then it is not necessary to maintain documentation in the permanent record unless the condition or incident was reportable to the state or unless the Program Director feels that the information may be needed in the future to substantiate the exit evaluation of the resident.

Adopted October 2009, Revised May 2011