Graduate Medical Education

Medical College of Wisconsin Affiliated Hospitals, Inc.

Institutional Policy
 

The MCWAH Administrative Office and the Training Programs each have record keeping responsibilities. 

MCWAH Office 

Employment Files

The following items are filed in the MCWAH Office.  After five years, records are saved permanently in an electronic format stored on the MCW Information System.

• Application with name, DOB, SSN, via status, educational background, start and completion dates
• Registrar confirmation of medical school graduation
• I-9 Forms
• Copy of ECFMG Certificate or verification report from ECFMG for IMG housestaff
• Visa documents if applicable
• Housestaff Graduate Medical Education Training Agreement
• Confidentiality Form
• Compensation records
• Election of benefits forms
• Leave of absence requests
• Copies of caregiver background information
• Verification of TEPs
• Medical license if applicable
• National Provider Identifier (NPI)
• DEA number
• Claims history from previous GME training if applicable
• Documents related to adverse education actions
• Summative evaluations
• Requests for accommodation 

Programs maintain the academic records for their residents and fellows (housestaff). Program Directors or their designees routinely respond to Privileging requests from hospital or credentialing agencies concerning former housestaff. The following documents should be saved permanently via hard copy, microfilm or electronically.

Medical Records

• Medical certification and fitness for duty reports shall be filed in the MCWAH office and are maintained in a file separate from his/her employment file. Records related to leave shall be saved for 3 years from the date the leave ended.
• Employee exposure records and medical records related to Workers Compensation will be filed and saved by MCW Occupational Health, on behalf of MCWAH, for the length of employment plus 30 years.
• All other employee medical records will be filed and saved by MCW Occupational Health on behalf of MCWAH for the length of employment plus 30 years.

Files for MCW Employed Housestaff in Accredited Programs

• Documents related to adverse education actions (Available on request by MCWAH to training program).
• Summative evaluations (Available on request by MCWAH to training program). 

PROGRAM FILES 

Programs maintain records related to the hiring process and academic records for housestaff.  Program Directors or their designees routinely respond to privileging requests from hospital or credentialing agencies concerning former housestaff. 
The following documents should be saved permanently in paper or electronic format on the MCW Information System:

Records Related to Recruitment

• Candidate applications in Association of American Medical Colleges’ Electronic Residency Application Service (ERAS) and documents related to the hiring process such as references and interview notes, must be retained for one year for all applicants. If applications are received from outside of ERAS, comparable information must also be retained for one year.  If there is an open claim or lawsuit, either civil or regulatory (i.e. EEOC claim) records must be kept until the matter is concluded.
• Recruitment records for housestaff shall be retained permanently.

Training File

Programs must have a training file and an application file for each housestaff.  The following items are included in the training file.

• Copy of Medical School Diploma (for housestaff starting before 9/1/2001)
• Results of in-training exams and any other data related to performance
• Evaluations
• Summative evaluations
• Documents related to adverse education actions
• Copies of Housestaff Rotation Schedules
• Documents related to moonlighting activities such as letters of the Program Director’s approval
• Specialty specific requirements such as case logs
• Evidence provided to another program of educational experiences for housestaff who transferred.
• Documentation of program completion

This revised policy was approved by the MCWAH Graduate Medical Education Council on July 18, 2011. The original policy was approved on April 15, 2002 and revised on March 20, 2006.