Resident Chart Closure Policy and Process

Here is a TL;DR summary and please see below for more details:

• The ultimate goal is that no clinician will have incomplete notes >30 days old.

• The best practice is to close clinic notes on the day of the encounter.

• The expectation is to close clinic notes within 72 hr of the encounter.

• If faculty have incomplete notes >30 days, their privileges will be suspended.

• If residents have incomplete notes >30 days, they will have a learning plan to provide professional development.

• In the past, residents signed their clinic notes and closed their own outpatient encounters, but now residents will assign a co-signer faculty, select "sign on accept," and the faculty will attest the note and close the chart. 

Below is a summary of the chart closure policy and residency co-sign changes. The words "note" and "chart" are used interchangeably below. For each patient encounter, there needs to be a clinical note, and the note needs to be written in order to close the encounter/chart.

UW chart closure policy highlights:

• It is important that everyone reads this important policy and the FAQs (Chart Closure Changes & Chart Closure Risk to Provider). 

• The chart closure policy trial started on June 13, 2023, and will go live on July 12, 2023. All incomplete notes >30 days old, need to be closed ASAP before July 12, 2023.

• The best practice for all clinicians is that both inpatient and outpatient notes should be completed on the day of the encounter. This is something you should aim to do whenever possible.

• Per this UW Health policy, the expectation for all clinicians is to complete inpatient encounter notes within 24 hr and outpatient encounter notes within 72 hr of the encounter. So, the longest you should have a clinic note open is 72 hr after the encounter and you should still aim for the best practice of completing notes on day of the encounter.

• Of note, these recommendations are not a significant change from our prior note closure policy (best practice has always been to close notes the day of the encounter and the prior expectation was to close notes within 48 hr of the encounter for outpatient visits). What differs is the process that happens if notes are open for extended periods of time. The goal with this policy is that no clinicians will have incomplete notes that are >30 days old.

• For faculty, incomplete charts at 30 days will result in suspension of privileges and will impact credentialing. This is not the case for residents. If a resident has an incomplete note at 30 days, it will NOT count as an incomplete note for the the faculty (faculty will not be penalized for incomplete resident notes), even though an incomplete resident note will show up in the incomplete encounters for faculty since faculty will now be closing all resident outpatient charts (see below). The take home point is that it is still very important to have resident notes completed in a timely manner so that faculty can close those encounters.

• For residents, clinic site leads will continue to monitor incomplete notes on a weekly basis for all clinicians (faculty, resident, APP) at their clinic, and if a clinician has incomplete notes that are 1 week old, the site lead will email that clinician a reminder to complete the charts. If residents have incomplete notes that are 2 weeks overdue, they will meet with the program director or associate program director to develop a plan to complete the open notes. If a resident has incomplete notes that are 30 days or more overdue, the resident will receive a formal learning plan from the residency program to develop a plan to complete the notes. 

Resident note cosign process highlights:

• Starting today June 14, 2023, there is a new process for how residents co-sign and close encounters.

• The inpatient process doesn't change much in that you will continue to co-sign your notes to the attending on service. 

• The outpatient note signing process changes. In the past to close a clinic chart, residents assigned a cosigner faculty, then signed a note, and closed the chart. The faculty would still cosign the note. With the new process, residents will assign a faculty co-signer to the note (there will be a box to add the co-signer at the top of the note template similar to inpatient notes) and select "sign on accept" at the bottom of the note. After doing this, the note should say "ready to be signed" at the top of the note. This note will then go to the faculty to add an attestation and close the chart. The encounter will appear as an incomplete encounter until the faculty co-signs the note. So, the process for an outpatient note is to finish the note and then add a co-signer-->select "sign on accept"-->and make sure it says "ready to be signed" at the top of the note.

Resident Epic Workflow:

1. You must now check the “Cosign required?” box at the top of your note if not already checked, and enter the name of the attending staffer in the box that will appear. This is similar to our inpatient note process.

2. Your note and any orders within the encounter need to be completed and signed for the attending to close the encounter.

3. The default option at the bottom of your note should be “Sign on Accept.” If you are still working on your note (aka you are NOT ready for the attending to sign and close the encounter), you will need to change your note status to “Pend on Accept.” When your note is complete, this needs to be set to “Sign on Accept” again. This is crucial, as the attending will not be able to close the encounter if the note is still in “Pend” status, but could prematurely close your encounter if you weren’t done with your note yet if you left it in “Sign” status.

4. The encounter will remain in your inbasket under “Incomplete Charts” until the attending has closed the encounter. While in inbasket, take note of the top bar which will either be green and say “Good to Go!” which means the attending can close the encounter, or red and list the specific items preventing the attending from closing the encounter that the resident will need to address.

If you are having challenges completing notes in a timely manner or want to discuss best practices for note completion, please reach out to Lash, Billy, or Tom or any of the chief residents. As with anything, becoming efficient with note completion takes practice, and there are approaches we can all learn that can help to improve this skill.