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Curtailment of Privileges for Incomplete Charts

Practitioners and Covenant Health share the responsibility to create and maintain an accurate health record of the care provided to every patient in Covenant Health facilities.

In accordance with the AHS and Covenant Health Medical Staff Rules (Section 4.21.4),  a shared AHS/COV process was initiated in 2012 for the Curtailment of Clinical Privileges for Incomplete Health Records.

According to the Rules, if at any time a Practitioner accumulates ten or more Patient health records that have been incomplete for more than 28 days after they have been provided to the Practitioner for completion, or any single Patient health record has remained incomplete for more than 90 days after it has been provided to the Practitioner for completion, the Practitioner is eligible for curtailment of clinical privileges. 

  • Practitioners will receive  regular listings of all incomplete health records (≤ 28 days old, 28+ days, 90+ days old and overall total from Health Information Management (HIM).
  • Once per month (2nd Wednesday), practitioners at risk for curtailment of privileges will be notified by Covenant Health Medical Affairs office.

 “At Risk” - refers to practitioners who have 10 or more incomplete records greater than 28 days of age or 1 incomplete record more than 90 days of age and are at risk of having their privileges curtailed if they do not complete their overdue records within 14 days.

  • On the 4th Wednesday of the month, if the practitioner has not completed the overdue records, and unless the Covenant Health Chief Medical Officer, determines that there are extenuating circumstances, he/she shall curtail the practitioner's clinical privileges at all sites (both Alberta Health Services and Covenant Health. A suspension letter will be sent to the practitioner via email or fax by Alberta Health Services.  An alert email regarding this suspension letter will be sent to the practitioner by Covenant Health Medical Affairs as well.
  • Privileges will be reinstated as soon as the practitioner has completed the overdue charts by Health Information Management (HIM) who will advise Covenant Health Medical Affairs Office.

During the period of curtailment, the Practitioner in default shall be permitted and expected to:

  • Continue to care for his/her own Patients (including any surgical care) admitted prior to the date of curtailment of Clinical Privileges.
  • Fulfil his/her obligations with regard to on-call responsibilities during which time the Practitioner may treat, admit and consult on emergent cases and provide coverage for Patients under the care of his/her Clinical Department service / colleagues.
  • Provide care for his/her personal maternity and newborn cases including admission where necessary.

During the period of curtailment, the Practitioner in default shall not be permitted to:

  • Admit Patients, other than his/her own maternity and newborn Patients, while not on-call.
  • Write orders (except while on-call) on his/her personal Patients who are admitted under the care of another Practitioner.
  • Treat Patients in his/her Site(s) of Clinically Activity except to continue to care for Patients for whom he/she was the Most Responsible Physician prior to the administrative suspension.
  • Perform surgery or Procedures, assist in performing surgery or Procedures or administer anaesthetics, except within the conditions described above. 
  • Provide consultative services, except within the conditions described above.
  • Accept transfers of Patients from within or outside the Facility, except within the conditions described above.

 Reference:

  • Alberta Health Services Medical Staff Rules (Feb 11) and 
  • Covenant Health Medical Staff Rules (Nov 11) Section # 4.21.4  Curtailment of Clinical Privileges for Incomplete Health Records

 Curtailment of Privileges (pdf)