36C24419R0052-014.pdf

Department of Veteran Affairs POLICY 16-16-215 Medical Center April 25, 2016 Wilkes-Barre, Pennsylvania 18711

HEALTH INFORMATION MANAGEMENT AND DOCUMENTATION

I. SCOPE/EFFECT: All employees are affected by this policy.

II. PURPOSE: To state responsibility, policy, and procedures to maintain adequate medical record documentation and content at this medical center.

III. POLICY: The Veterans Health Administration (VHA) medical record will reflect the highest quality of care, comprehensiveness, clarity, interdisciplinary communication, research, training, and patient education. Electronic storage and capture of patient medical information will be implemented to the extent possible to enhance access to patient data by health care providers and support personnel. The electronically stored and/or printed patient information is subject to the same medical and legal requirements as the handwritten information in the medical record. All health care delivery (inpatient, ambulatory care, ambulatory surgery/invasive procedures, etc.) at the medical center will be systematically documented. Medical records will be maintained, processed, and protected in such a manner that meets the legal and clinical requirements of the VHA Handbook 1907.01, March 19, 2015 and applicable accrediting bodies.

IV. PROCEDURES:

A. Electronic Signatures

1. Legal Considerations: The electronic signature will appear on computer-generated medical record documents to authenticate and/or countersign medical record entries. These documents may include, but are not limited to, discharge summaries, reports of procedures/operations, patient-related orders, consults, progress notes, radiology and nuclear medicine reports. The electronic signature will be treated as a written signature with all of the ethical and legal implications thereof. The electronic signature is invalid for and will EXCLUDE all Schedule II controlled substances. Only hard copy prescriptions will continue to be accepted for Schedule II controlled substances.

2. Security: Electronic signature codes are encrypted in the computer system so that no one, including Facility Information Technology Service (FITS) staff, has access to the codes. If a user forgets their electronic signature code FITS can delete the code and allow the user to assign another code.

B. Type of Signatures

1. “Signer” is the author of the document. Once a document is signed, it cannot be edited; additional documentation can be added to the original document by addenda.

2. “Co-signer” is a supervising practitioner. A co-signer may also be a service chief, or designee, as defined by the organization’s By-laws and/or policies.

3. “Additional signer" and "identified signer" are synonymous and are a communication tool used to alert a clinician about information pertaining to the patient. This functionality is designed to allow clinicians to call attention to specific documents and for the recipient to acknowledge receipt of the information. Being identified as an additional signer does not constitute validation, authentication or co-signature. Additional signer or identified signer is not acceptable for Residency Supervision compliance.

C. Management of Patient Records

1. The administrative management of the patient's record is the responsibility of Chief HIM and the clinical management of patient records is the responsibility of each professional service contributing to the content of the patient record. Health Information Management Section will provide leadership with recurring reports to assist in the assessment of the adequacy, timeliness and completeness of the patient record.

2. All patient information is either entered electronically or scanned into CPRS using VistA Imaging. After imaging and verification, the hard copy document is destroyed. Should an inactive paper administrative or medical record be needed, Record Manager Officer will request the record from the Federal Record Center either by fax or secure courier service depending on the urgency of the situation.

Please refer to MCP 16-15-421 Document Scanning Policy.

3. Ownership: All medical records and printed copies of electronic patient records are the property of the VA and shall not be removed from the medical center except for the purpose of responding to an order from a court of competent jurisdiction or in accordance with Veterans Affairs (VA) regulations as defined in 38 CFR 1.511- Disclosure of claimant records in connection with judicial proceedings.

D. Access

1. Access to patient records will only be granted to authorized staff with a need to review or enter documentation in the patient record to provide patient care or to perform administrative functions within their assigned job duties. Such access will be restricted by menu option and key, as well as by access and verify codes.

a. Access will also be given to qualified staff for study or research approved by the Institutional Review Board and Research and Development Committee and consistent with preserving the confidentiality of personal information of individual patients.

b. Access will be given to qualified staff for quality or patient safety improvement activities.

c. Every employee with access to patient records is responsible and accountable for safeguarding patient confidentiality and privacy, and failure to do so can result in disciplinary action.

(1) Abbreviations and Symbols: Medical abbreviations and symbols shall be restricted to those approved by the Medical Records Committee. No symbols or abbreviations will be used when documenting final or discharge and pre and post- operative diagnoses and procedures for patients released from inpatient, ambulatory care, and/or outpatient services. The facility has a listing of abbreviations that cannot be used (“Non-approved Abbreviations”) in the patient record. The Do Not Use Abbreviations List is available through CPRS. It can be found from the “Tools” menu under the category “Dangerous Abbreviations”.

(2) Timeliness of Entries: The required timeframes for entry of admission history and physical examinations, operative reports, and discharge summaries are defined in the Medical Staff Bylaws. Timeframes are also defined for the entry of progress notes, orders and reports of diagnostic and therapeutic procedures.

(3) Forms, Templates and Note Title Management: The Medical Records Committee (MRC) has a subcommittee which reviews all forms, templates and Note Title management. The MRC is responsible for reviewing and approving all electronic templates and overprinted health record documents. The forms and templates will be reviewed for legal, policy, regulatory compliance and ease of use. Requests for forms and/or templates must be approved prior to execution. Note title requests will be compared by Clinical Applications Coordination (CAC) staff to VHA national guidelines prior to submission to and approval by MRC.

Standardized note titles facilitate the retrieval of specific patient information. Issues regarding note title standardization are part of the health record review function. NOTE: As nomenclature evolves, note titles will be standardized. Proliferation of note titles makes retrieval difficult and cumbersome.

E. General Procedures

1 Medical records are confidential under the Privacy Act/Health Insurance Portability and Accountability Act and will not be accessible to, or discussed with, unauthorized persons. Please refer to Privacy Policy 01P-15-717 for facility policy and procedures.

2. Only authorized individuals designated by Wilkes-Barre Medical Center Rules, regulations, and bylaws may make entries in medical records. These authorized individuals are approved by the medical staff as outlined in the Medical Staff Bylaws. This includes staff that, by virtue of their position description, functional statement, or scope of practice when providing patient care, are authorized to document that care in the medical record. All entries made to the medical record will be legible, intelligible, dated, and authenticated to identify author by written or electronic signature.

3. Prompt completion of records is mandatory. Inpatient records will become delinquent 30 calendar days, or as designated by Medical Center Bylaws, after the patient's discharge if not completed by the responsible health care professional(s).

4. No medical staff member is to be required to authenticate entries of an unfamiliar patient in order to retire the record for a staff member who is deceased or unavailable permanently or protractedly for other reasons that are not the staff member's own in order that a record on an unfamiliar patient may be filed. The patient record will be declared complete for the purpose of filing only on the order of the Chief of Staff based on the recommendation of the Medical Records Committee. Any record declared complete on the order of Chief of Staff will bear a notation giving the circumstances under which the record is being filed. The Chief of Staff or designee will sign documents that are electronic and cannot be accessed in CPRS. In this case the following statement will be used to administratively complete the record, “This record is being closed administratively due to the fact that the provider is permanently unavailable.” This statement does not legally imply that the signer is validating the contents of the document but is only administratively completing the medical record. This statement will not be used to close records due to the failure of an available provider to sign his/her documents.

5. Entries written by medical students that are co-signed by the responsible physician will become a part of the treatment record. Clinical services and job titles that require direct patient contact are authorized to document these interactions in CPRS.

6. Social Work Service personnel create an advance directive note in CPRS.

7. Social workers will document in the existence of an advance directive or power of attorney in CPRS.

8. The Health Information Management Scanning section staff is approved to scan documents that cannot be computerized via CPRS.

a. Inpatient, ambulatory surgery/invasive procedures and outpatient medical records will be complete and include original signed or electronically signed documents relating to the veteran's admission, care, treatment, response to treatment, and discharge plan, including therapy and disposition. Documents including results/reports of diagnostic studies are available in VistA Imaging.

Paper documents will be scanned into VistA Imaging, verified and then destroyed.

b. Entries should not contain facetious, libelous, or otherwise inappropriate or subjective remarks. Personal opinions or non-medical judgments shall not be expressed in the medical record, except as they pertain to the direct medical care of the patient.

c. Only those symbols and abbreviations listed in MCP 16-14-225 “Standard List of Abbreviations and Symbols” approved abbreviations list will be acceptable in the medical record. Abbreviations should be used judiciously.

Abbreviations listed on the non-approved list will not be used in the medical record.

d. The medical record should explicitly document efforts made by the staff in the area of patient education in accordance with MCP 113-15-130 “Veterans Health Education and Information” and appropriate regulatory agency. Patient education should be interdisciplinary and documented in CPRS. Such interactions as patient and family counseling should also be documented in CPRS. When appropriate, the patient should be educated on:

Safe and effective use of medications;

(1) Safe and effective use of medical equipment;

(2) Nutrition interventions, modified diets or oral health;

(3) Rehabilitation techniques;

(4) Available community resources;

(5) Self-care activities;

(6) Pain and effective pain management; and

(7) When to seek further attention.

F. Copy and Paste

1. Medical record documentation is to provide an accurate depiction of treatment surrounding a specific date of service. It is unnecessary to duplicate, either by use of copy and paste, importing text, objects or by use of templates, information that does not specifically impact a new specific episode of care.

2. Clinical, ethical, financial, and legal problems may result when text is copied in a manner that implies the author or someone else obtained historical information, performed an exam, and/or documented a plan of care when the author or someone else did not personally collect the information at the time the visit is documented.

3. The problem list is a reflection of all of the patient's medical problems, past or current, and may or may not be relevant to a specific episode of care. Only those diagnoses that were addressed or impact a specific episode of care should be included in a note. Do not copy entire problem lists into a note, unless a review of past problems are a component of the episode of care.

4. Do not copy a signature block and/or a prior episode date into another document.

5. Templates with standard wording can be a timesaver; however, each progress note should be succinct recapitulation of a unique episode of care. If templates are used, the wording should be changed as appropriate from visit to visit to reflect the current care given. Default responses are not allowed in templates.

Instead, choices are to be designated by check boxes or radio buttons.

Exceptions to this practice will be evaluated on a case-by-case basis.

6. All information imported via patient data objects such as vital signs, past laboratory results and medications should be verified prior to signing the note.

The medical record is a legal document and is expected that an entry is an accurate and complete representation of that encounter.

7. E-mail interactions between patient and providers may not be copied into CPRS, as e-mail communications are not secure. A brief summary of the patient's e-mail may be entered into the chief complaint or subjective section of the medical record.

8. It is not permissible to copy information that identifies a healthcare provider as involved in care that the healthcare provider is not involved in.

9. Do not re-enter previously recorded data unless specifically required for the assessment of a specific patient problem.

10. Do not copy entire laboratory findings, radiology reports, and other information in the record verbatim into a note when it is not specifically addressed or clearly pertinent to the care provided.

11. Use the functionality of importing data objects into progress notes and other documents judiciously. Facility policy needs to state that any imported object, dialog, etc., if used, must be reviewed and corrected at the source as well as in the document if there is any inaccuracy, and it must be pertinent to the patient assessment.

12. It is acceptable to refer to current documentation in CPRS that was reviewed rather than repeating or inserting the information by copying and pasting. This can be accomplished by a statement that the documentation was reviewed, e.g.

nurse's note from 1/1/06 reviewed.

13. It can be acceptable on rare occasions to copy information from one part of the record to a current progress note ONLY if it is critical that information be repeated in the current note and it has a direct impact on care rendered during that encounter.

G. Clinician Accountability

1. The authors are liable for the content of copied items within the notes they authenticate. As part of the health record review function, use of copy and paste functionality must be monitored and where violations occur, findings must be reported to the appropriate Health Services Committee for disciplinary or other adverse action. NOTE: Criminal charges may be filed when in violation of Federal law.

2. Failure to comply with these standards may be deemed a violation of the:

a. Privacy Act requirement (5 U.S.C. Section 552a(e)(5)); or

b. Standards of Ethical Conduct of Employees of the Executive Branch (5 CFR Part 2635).

c. Disciplinary action may be taken if violations of there standards are validated per VA Directive 5021. Violations are:

(1) Charge 05 - Careless or negligent workmanship resulting in waste or delay.

(2) Charge 11 - Failure to safeguard confidential information.

(3) Charge 12 - Deliberate failure or unreasonable delay in carrying out instructions.

(4) Charge 25 - Falsifying official agency records.

3. Health Record Alterations and Modification: There are four types of health record changes for completed documents:

b. Administrative Update: An administrative update is current information entered in place of existing data, i.e., an address change or other registration data, etc.

c. Administrative Correction:

(1) An administrative correction is remedial action by administrative personnel with the authority to correct health information previously captured by, or entered in, error. Administrative corrections include factual and transient data entered in error or inadvertently omitted.

Administrative corrections are not initiated by the veteran.

(2) The Chief HIM or designee, may take administrative action on an incorrect note entry in the following circumstances:

(a) The note is entered in duplicate;

(b) The note is entered into the wrong patient's record;

(c) The note is entered with incorrect information.

(d) An addendum is entered into the wrong patient's record.

(3) The author must notify the Chief HIM or designee via the established process for Medical Record Corrections.

(4) The author writing the note must enter an addendum to the note containing the Medical Record Correction template where he/she shall state why the note is incorrect; and the Chief HIM or designee will then delete the note the status to retracted, which will no longer allow authors to view the contents of the note.

(5) Any retraction or rescission of entry must be initiated by the author or originating discipline. Laboratory, radiology, and pharmacy are examples of disciplines that may initiate retractions or rescissions within their own packages.

(6) Documents scanned in error; see MCP 16-15-421 “Document Scanning Policy”.

d. Addendum

(1) An addendum to a patient note or summary is made when a clinician deems it important to clarify information recorded in the original document or to add to the original document. The addendum option can be utilized by practitioners to continue ongoing treatment discussions or by supervising practitioners to validate the plan of care.

(a) Addenda are linked to originally created documents

(b) Addenda must be authenticated in an approved manner

(c) Addenda may be entered by someone other than the author.

The original author may be alerted to this action if appropriate

(2) A new note by the practitioner must be initiated for each new patient contact rather than using an addendum.

e. Amendment

(1) Amendment is the alteration of health information by modification, correction, addition, or deletion at the request of the patient or veteran as allowed under the Privacy Act of 1974 and Health Insurance Portability and Accountability Act (HIPAA). A request to amend any data contained in VHA records must be submitted in writing to the facility Privacy Officer, or designee, by the veteran stating explicitly what information is in contention and why inaccurate or erroneously, irrelevant, untimely, or incomplete.

(2) When a request to amend a record is approved, the disputed information must be corrected or deleted using the TIU AMEND action.

The TIU AMEND action automatically keeps the original, un-amended document with status retracted. Requests for amendments must be tracked and information recorded appropriately for disclosure purposes.

(3) VHA may deny the request to amend the health record, as indicated in VHA Handbook 1605.1, if the health information that is the subject of the request:

(a) Is not part of the individual's health record; or

(b) Is accurate, relevant, timely, and complete in the present health

(4) The TIU AMEND action automatically includes the notation “Amended–Privacy Act” on the new, amended document. The document is authenticated with the date, signature, and title of the person making the amendment. The date, signature, and title should not be made within the body of the electronic document, as they will be included automatically when the document is printed or displayed.

(5) When a statement of disagreement or the amendment process documents are requested to be filed with the disputed information by the veteran, the statement or documents must be appended or otherwise linked to the veteran’s record. This is accomplished by adding an addendum to the disputed information indicating where the statement or documents are filed.

f. The following electronic options for correcting data are currently available for un-authenticated documents:

(1) Deletion: An author may delete a patient document prior to electronic signature. Electronically signed documents that are totally blank are deleted monthly by the Health Information Management Incomplete Records section.

(2) Change Title: When a note title is electronically modified, the title is changed from the previous title to the new title; a change history of the title name is not maintained. If the title of an unsigned note is incorrect, the author or a CAC may change it to the appropriate note title. If the title of a signed note is incorrect the Chief HIM or designee may change it to the appropriate note title at the request of the author.

g. Chief HIMS will provide the oversight for the business rules. The Medical Record Committee will ensure a yearly review and the result findings of the facility’s business rules will be discussed at the Medical Record Committee, meeting and appropriate action taken.

H. Medical Record Documentation

1. Inpatient Documentation:

a. The primary source of documentation for all patient care activities shall be the CPRS. Any generated paper records needs to be remained intact, and should be located so that there would be no delay in its availability for use in an emergency by professional or administrative personnel.

b. Health Records must be complete and available for the provision of patient care according to the facility’s Bylaws, but not greater than 30 calendar days from the date of discharge.

c. Inpatient Documentation must include the following:

(1) History and Physical (H&P): A complete inpatient admission History and Physical examination will be performed and completed within 24 hours of admission, or prior to surgery, and must be signed by a physician on the acute medical and/or acute psychiatry units. In a nursing home, an H&P must be available within 72 hours of admission.

(a) Attending must complete an individual note or addendum within one calendar day. The supervising practitioner must physically meet, examine, and evaluate the patient within 24 hours of admission including weekends and holidays. Documentation of the supervising practitioner’s findings and recommendations regarding the treatment plan must be in the form of an independent progress note or an addendum to the resident note, which must be entered by the end of the calendar day followingadmission.

(b) The history will include the chief complaint and details of the present illness including, when appropriate, assessment of the patient's emotional, behavioral, and psychosocial status.

(c) The physical examination will reflect a comprehensive and current physical assessment.

(d) The Medical Staff will document the initial impression (provisional diagnosis) and the need for further assessment. Opinions of the interviewer ordinarily will not be recorded in the body of the history.

(e) When requested by the medical staff, an oral examination and treatment will be completed by a qualified member of the Dental Service. Findings on the examination and treatment will be recorded in the medical record.

(f) IF A PATIENT IS READMITTED WITHIN 30 DAYS OF A

HOSPITALIZATION FOR THE SAME OR A RELATED CONDITION,

an interval (updated) H&P is required which should reflect subsequent changes, and will be placed in the medical record within 24 hours of admission. An original signature and date are required.

1_An interval H&P, when used, will be documented on the progress note within 24 hours and contain the following:

a_ A statement that the previous H&P has been reviewed, the date of the previous H&P, and there are pertinent changes to the history or physical findings which will be specified; or b_ A statement indicating that the H&P has been reviewed and there are no changes.

2_Readmission after 30 days will require the completion of a new history and physical recorded in the progress note section of VistA.

In the event of multiple admissions, AN INTERVAL NOTE MAY ONLY

BE USED ONCE DURING A 30-DAY PERIOD.

(g) Subsequent Inpatient Notes: Attending physicians are expected to be personally involved in the ongoing care of patients assigned to them in a manner consistent with the clinical needs of the patient and the graduated level of responsibility of the resident. Acceptable documentation includes:

1_ Independent note by the attending physician;

2_ Addendum to resident’s note by attending physician;

3_ Countersignature of resident’s progress note by attending physician**;

4_ Resident progress note documenting the attending physician’s name and a statement of his/her concurrence with care;

**NOTE: Attending physician’s counter signature signifies that he/she has reviewed the resident’s note and concurs.

(h) Progress Notes

1_ Progress notes facilitate the communication among disciplines concerning the patient’s care. Members of the patient care team will document observations, progress, response to and changes in treatment, subsequent assessments of the patient’s response to care, other intervention, planned follow-up care, instructions, diagnosis, and pertinent findings from ancillary tests.

Every episode of clinical care will be documented by the respective clinical staff as defined by their scope of practice or job description in a progress note.

2_ Progress notes will be typed into CPRS whenever possible by the Residents, Registered Nurses, Licensed Practical Nurses, Rehabilitative Medicine Therapists, Dietitians, Social Workers, Psychologists, and other clinical staff to facilitate a multidisciplinary cooperation and approach to care.

3_ Progress notes will give a pertinent chronological report of the patients, course, and change in condition, response to medications and plans for the results of treatment particularly relative to diagnostic assessment and therapeutic efforts.

4_ Documentation is required when there is a history of allergies, adverse reactions or other conditions in the electronic record. The appropriate title must be used to trigger patient postings, as in Crisis Notes, Warnings, Adverse Reactions/Allergies, Directives (CWAD).

5_ Intensive Care Units (ICU): For patients admitted to or transferred into an ICU of the medical center, the supervising practitioner must physically meet, examine, and evaluate the patient as soon as possible, but no later than 24 hours after admission or transfer, including weekends and holidays. An admission note or addendum to the resident’s admission note is required within one day of admission. Because of the unstable nature of patients in ICUs, frequent evidence of involvement of the supervising practitioner is expected

(i) Inpatient Consultations: Consultation requests will be entered electronically through CPRS by the service requesting the consultation. The Consult Service Package is used to request a consultation and Consult Note Titles must be used to close out pending or open consultations. The request will include a brief description of the patient’s condition, reason for the consultation and other information of value (such as medication which may affect the condition being evaluated) and the electronic signature of the requesting practitioner.

1_ The consultation report will contain a dictated or electronically entered opinion and/or recommendation by the consultant. This report shall show evidence of review of patient’s record by the consultant, pertinent findings on examination of the patient, date of the consult and electronic signature, and linked to the consultation request.

2_ Consultations should be performed as soon as possible following the request to insure proper treatment of the patient and to prevent prolongation of hospital stay. Emergency consultations should be requested as “stat” and completed as soon as possible depending on the urgency. Refer to MCP XXX “Consultations”.

3_ The attending physician is responsible for clinical consultations from each specialty service, and is responsible for the supervision of residents involved in consultative services.

Acceptable documentation includes: Independent note by the attending physician; Addendum to resident’s note by attending physician; Countersignature of resident’s note by attending physician; and Resident’s note documenting the attending physician’s name and a statement of his/her concurrence with care.

(j) Doctor's Orders: All diagnostic and therapeutic orders by medical staff members, residents, and other physicians within the authority of their clinical privileges granted at this facility will be entered electronically by authorized personnel who will be identified by title and category in the Medical Staff By-Laws. Orders for admission, discharge and transfer are required as appropriate to the patient’s status and condition. Admission, Discharge, and Transfer Orders must be entered and signed by a physician at the time of Admission, Discharge, and/or Transfer. Only a physician can use the “discontinued” function from an order. Procedures for orders are detailed in CPRS → Tools → Clinical Info → CPRS → CPRS Training.

1_ A physician’s order is also required when:

a_ A patient’s right to visitation and communication by telephone and sealed mail is restricted. This order must be reviewed periodically to determine continued applicability with MCP 122-15-393, “Patient/Resident Rights and Responsibilities”.

b_ Restraint and seclusion of patient is required. Physician must specify the number of hours for restraints and seclusion.

PRN orders for restraints are not acceptable. Detailed requirements for restraints and seclusion are contained in MCP 108-14-103, “Behavioral and Non Behavioral Restrains”.

c_ Suicide or special observation is required as per MCP 108- 13-563 “Levels of Patient Observation”.

d_ In case of DNR and DNI orders: When a patient requests DNR, the attending physician must write the DNR order and a progress note in the patient’s medical records specifying that the order is written in pursuant to, and in accordance with the patient’s wishes. DNR orders remain in effect for the duration of the current admission, unless specifically revoked, and are not subject to renewal. Please refer to MCP 111-15-113 “Do Not Resuscitate”.

2_ Orders for medications must be identified by name, strength, route of administration, and frequency. Abbreviation use for medication orders is not authorized. Medication orders must be reviewed and rewritten when a patient is transferred between services and/or specialties.

3_ Verbal and telephone orders of authorized practitioners may be electronically entered by authorized personnel who will be identified by title and category in the Medical Staff By-Laws.

Such verbal and/or telephone orders must be authenticated by the responsible practitioner within MCP 11-14-65 “Physician Orders”. All responsible practitioners that receive verbal or telephone orders must follow a read back process for validation purposes.

(k) Inter-service and Inter-ward Transfers: The supervising practitioner, in consultation with the resident, ensures that the transfer of the patient from one inpatient service to another or transfer to a different level or care is appropriate and based on the specific circumstances of the patient’s diagnoses and condition. The supervising practitioner from the transferring service must be involved in the decision to transfer the patient. The supervising practitioner from the receiving service must treat the patient as a new admission and must write an independent note or an addendum to the resident’s transfer acceptance note.

(l) Discharge Progress Note: A discharge progress note/instruction sheet must be entered into CPRS upon discharge of the patient. It must contain the date of discharge, diagnosis, medications, recommendations relative to diet, exercise, condition on discharge, and future appointments/follow-up.

(m) Hospital Summary (Discharge Summary)

1_ The discharge summary needs to be prepared for all releases from VHA care, including deaths. A discharge summary must be documented for patient transfers to a VHA domiciliary care, VHA nursing home, VHA medical centers, or a private health care facility. Please refer to MCP 11-14-570 “Interdisciplinary Care Planning”. For emergency transfers to another facility, reason for transfer, stability of patient, acceptance by the receiving organization and a determination of responsibility during transfer must also be documented (refer to VHA Handbook 1907.1 for Documentation on Emergency Transfers).

2_ Discharge summaries should be documented prior to discharge, or within 24 hours of death or irregular discharge (refer to VHA Handbook 1907.1 for Discharge Summary). When the discharge summary is completed more than 24 hours prior to discharge, an addendum is required MCP 11-14-570 “Interdisciplinary Care Planning”.

3_ Transfer summaries must be documented by the time of patient’s discharge or transfer and according to MCP 00Q-13- 1406.

4_ Irregular Discharge/Against Medical Advice (AMA) and death summaries should be documented in accordance with MCP 16- 15-61 “Release/Discharge From Inpatient Care” after the patient vacates the premises or dies. Any patient leaving against medical advice must have a final progress note written by a physician indicating any known reason for leaving and any special disposition arrangements (refer to VHA Handbook

1907.01 for Discharge Progress Note and/or Discharge Instructions).

5_ The principal diagnosis (reason for admission) and all secondary diagnoses should be documented. No abbreviations are acceptable.

6_ The discharge summary must contain the following:

a_ Principal Diagnosis/Reason for Admission - The diagnosis determined, after studies, to be chiefly responsible for the hospital admission.

b_ Secondary Diagnoses - Additional diagnoses, conditions, and situations, which exist at the time of admission or develop subsequently which affect the treatment received and/or the length of stay. These should be listed in order of severity.

c_ Procedure(s)/Operation(s) - All significant procedures/operations performed during this admission should be documented.

d_ History of Present Illness - Description of significant findings which reflect the reason for hospitalization and past history significant to present illness; i.e., pertinent illnesses, known significant surgeries, allergies, family and social history, etc.

(1_) Physical Examination - Significant findings obtained on physical examination related to present hospitalization.

(2_) Diagnostic Findings – Diagnostic findings relevant to the conditions treated/diagnosed. Negative findings may be as pertinent as positive ones.

(3_) Hospital Course - Medical and/or surgical treatment, complications, response to treatment, and condition of patient on discharge, stated in terms that permit a specific measurable comparison with condition on admission. A discharge summary for a death should include events leading to the death, time patient pronounced dead, and a statement that an autopsy was or was not requested and/or performed.

(4_) Discharge Medications - Medications prescribed at the time of discharge to include dosage, route, and length of time to be taken.

(5_) Discharge Instructions - The patient's condition on discharge, level of understanding of condition, and instructions provided to the patient and/or other responsible party will be documented. Instructions will emphasize:

(a_) Discharge medications;

(b_) Diet instructions;

(c_) Physical activity and/or limitations, including convalescent period and when employment may resume, if applicable;

(d_) Instructions for follow-up care, scheduled return appointment(s), referral to another agency, or statement that no further care is required; and;

(e_) Statement of competency for VA purposes, if appropriate;

(f_) When to seek further care (clinician must document signs and symptoms of when further treatment is needed).

(n) Nursing Home Documentation:

1_ Nursing home care consists of a dynamic array of services, such as, but not limited to: short stay skilled nursing, rehabilitation, hospice or an array of longer stays such as dementia or maintenance care for veterans who have sufficient functional impairment and/or nursing and medical needs that can not be provided in other non-institutional settings.

2_ Short-stay nursing home care is for admissions that are 90 days or less, and long-stay is for admissions greater that 90 days.

3_ Nursing home documentation must include the following:

a_ Resident Assessment Instrument Minimum Data Set:

Standardized instrument specifically designed for nursing home initial assessment, regular assessment and treatment planning. Use of electronic version of Resident Assessment Instrument Minimum Data Set is required for all nursing home admissions.

b_ Initial Assessment: Nursing home care requires the Minimum Data Set be completed within 5 days for a designated short stay admission (90 days or less) and 14 days for a designated long-stay admission (greater than 90 days). Initial discipline specific screening and assessments must be completed as required for each discipline by facility policy and Joint Commission standards for nursing care.

c_ History and Physical

(1_) Must be available within 48 hours of admission.

(2_) If the patient’s stay exceeds 365 days, an annual exam should be performed.

(a_) Re-assessments: Reassessments are conducted for short-stay and long-stay residents according to the Resident Assessment Instrument Minimum Data Set (RAI MDS) policies.

(b_) Treatment Plan and/or Care Plan: The care plan indicates the goals and frequency of interventions to achieve those goals.

• The care plan is coordinated by an interdisciplinary team consisting at a minimum of a registered nurse, social worker, recreation therapist, and dietician. Other members of the interdisciplinary team include, but are not limited to the: medical provider, pharmacist, mental health professional, and rehabilitation therapist.

• The initial treatment plan for short-stay residents must be completed within 21 days of admission.

• Short-stay residents must be reassessed every 14, 30, 60, and 90 days.

• The initial treatment plan for long-stay residents must be completed within 21 days after admission.

• Long-stay residents must be reassessed every 90 days or when there is a significant change in condition.

(c_) Orders: Orders must be reviewed and/or rewritten monthly. Provided no changes are made to the others, the monthly review may be documented by simply writing “continue” or “renew.”

(d_) Discharge Summary d_ Hospice Documentation:

(1_) Hospice is a mode of palliative care that generally signifies the presence of a terminal condition, a life expectancy deemed to be less than 6 months, and the decision to not pursue aggressive measures with curative intent.

(2_) All documentation should be completed by the Interdisciplinary Treatment Team (ITT), the core collaborative body that oversees the comprehensive whole-person care for all patients. The ITT typically consists of the following members:

(a_) Physician, nurse practitioner, physician assistant

(b_) Registered Nurse (RN), Licensed Practical Nurse (LPN), patient care assistant, and nursing assistant

(c_) Social worker

(d_) Spiritual Counselor

(e_) Dietitian

(f_) Pharmacist

(g_) Inpatient settings also include recreation therapists and other rehabilitation staff e_ Documentation should include the following:

(1_) History and Physical

(2_) Life-limiting illness of the patient

(3_) Notification of patient/family/DPOA of the diagnosis and prognosis

(4_) Code Status

(5_) Identifying/implementing management of comfort issues such as pain, dyspnea, constipation and diarrhea, nausea and vomiting, depression and anxiety f_ Treatment Plan: The treatment plan should be documented in CPRS by the Interdisciplinary Treatment Team, and should address the following:

(1_) Diagnosis and prognosis;

(2_) Care alternatives and treatment settings (in-home, community, and institutional programs);

(3_) Advanced Directives;

(4_) Advance Care Plans;

(5_) Psychosocial assessment and, as needed, counseling;

(6_) Spiritual assessment and, as needed, counseling;

(7_) Involvement of the veteran/family/DPOA in decision-making and participation in care;

(8_) Palliative symptom management to include but not limited to pain control, dyspnea, nausea and vomiting, anorexia, constipation/diarrhea, depression, and anxiety/insomnia

(9_) Advance Care Planning: A note that includes discussions of the patient’s wishes regarding life-sustaining treatments, quality of life, hospice care and related comfort care issues g_ Blind Rehabilitation Records: Visual Impairment Service Team (VIST) staff will document the veteran's performance in accordance with MCP 117-14-995 “Visual Impairment Services Program”.

The VIST patient record documentation requirements will follow the same requirements as outpatient medical records.

This facility currently does not offer inpatient services.

h_Outpatient Documentation

(1_) Each time a patient visits the ambulatory care setting, a progress note will be recorded through CPRS.

Documentation should contain the time and means of arrival, chief compliant (ED only), degree of history, examination and medical decision making to support the evaluation and management assigned to the visit.

Documentation must also include the following when appropriate: date and clinic name, clinical observations, basis for ordering test, if any changes in medication or new medication, results of treatment, reports of tests, procedures performed, tests, conclusion, disposition and discharge instructions including level of understanding, attending physician’s name and level of involvement, and signature and date. If the patient leaves against medical advice (AMA), the physician must document the circumstances in the progress note in CPRS.

(2_) Intensity of the level of service rendered must be reflected in the note.

(3_) The summary (problem) list will be initiated and maintained by the third visit for continued ambulatory care patients to the health care provider and shall include known significant diagnoses, known significant operative and invasive procedures, known adverse drug reactions, allergies, and a list of current medications, including over-the-counter drugs and herbal preparations. The summary list will be composed of the cover sheet and the problem list that already exists in the Graphic User Interface (GUI) in CPRS. The summary list is updated whenever there is a change in diagnosis, medications or allergies to medications and whenever a procedure is preformed.

(4_) The clinicians are encouraged to resolve clinical reminders as a means to document the assessment and counseling of chronic disease indexes and preventative health issues.

(5_) Cancelled appointments or termination of treatment will be annotated in the progress notes.

(6_) Ambulatory Surgery/Medicine Records - Documentation of operative/invasive procedure requirements are referenced in the MCP 112-13-234 “Ensuring Correct Site Surgery and Invasive Procedures”.

(7_) When a patient is admitted as an inpatient from outpatient/ambulatory care, a progress note that provides the reason for referral to inpatient care will be completed.

(8_) The health care practitioner must document a pertinent progress note at the time of each ambulatory and/or outpatient care visit. Cancelled appointments or no-shows are viewable on the CPRS cover sheet.

(9_) The physician or health care practitioner must document only those diagnosis(es) treated during an encounter or that require further treatment. An assessment as to whether continued care, on an ambulatory or outpatient basis, is required must be documented following the diagnosis.

(10_) Elements for chronic disease indicators and prevention measures must be documented when appropriate.

(11_) The practitioner must document a termination of care summary note when it has been determined that care is no longer required. The termination of care summary note must include: the condition on discharge, any patient instructions, and any relevant diagnoses, operations, and findings.

(12_) New Outpatient Encounters: Each new patient seen by an outpatient clinic for which the attending physician is responsible needs to be seen by or discussed with the attending physician. Acceptable documentation includes:

(a_) Independent progress note by the attending physician;

(b_) Addendum to resident’s progress note by attending physician; and

(c_) Resident progress note documenting the attending physician’s name and a statement of his/her concurrence with care.

(13_) Established Outpatient Encounters: The attending physician must be identifiable for each resident’s patient care encounter. Return patients must be seen by, or discussed with, the attending physician at such a frequency as to ensure that the course of treatment is effective and appropriate. Acceptable documentation includes:

(a_) Independent progress note by the attending

(b_) Addendum to resident’s progress note by attending physician;

(c_) Countersignature of resident’s progress note by

(d_) Resident progress note documenting the attending physician’s name and a statement of his/her concurrence with care (at a minimum the attending physician’s name must be documented).

(14_) Progress notes facilitate the communication among disciplines concerning the patient’s care. Members of the patient care team will document observations, progress, response to and changes in treatment, subsequent assessments of the patient’s response to care, other intervention, planned follow-up care, instructions, diagnosis, and pertinent findings from ancillary tests.

Every episode of clinical care will be documented by the respective clinical staff as defined by their scope of practice or job description in a progress note.

(a_) Progress notes will be typed into CPRS whenever possible by the house staff, registered nurses, licensed practical nurses, rehabilitative medicine therapists, dietitians, social workers, psychologists, and other clinical staff to facilitate a multidisciplinary cooperation and approach to care.

COS must approve the dictation of progress notes.

(b_) Progress notes will give a pertinent chronological report of the patients, course, and change in condition, response to medications and plans for the results of treatment particularly relative to diagnostic assessment and therapeutic efforts.

(c_) Documentation is required when there is a history of allergies, adverse reactions or other conditions in the electronic record.

(d_) Doctors may dictate any outpatient progress notes. All outpatient progress notes must be authenticated within 7 days.

(e_) Discharge Order must be entered when patients are being discharged, left AMA or expired from the TR house.

(f_) Discharge Summary: A discharge summary will be dictated by the physician assistant for the TR house the day the resident is discharged from the TR house and the contents will conform to the documentation requirements set forth in the medical center memorandum. The attending physician/psychiatrist must authenticate the discharge summary within 30 days of discharge.

(15_) Outpatient Consultations: A supervising practitioner is responsible for clinical consultations from each outpatient clinic to another supervising practitioner within the Medical Center. When residents are involved all of the four types of documentation is acceptable.

(16_) Emergency Department (ED): Each new patient admitted to the ED must be seen by the attending physician or the resident must discuss each new patient with the attending physician. Fellows moonlighting in the ED are considered attending physicians.

(a_) Acceptable documentation includes:

• Independent note by the attending

• Addendum to resident’s note by attending physician; and

• Resident note documenting the attending physician’s name and a statement of his/her concurrence with care.

(b_) ED Consultations: When a resident is involved in a consultative service, the resident’s attending physician is responsible for supervision (not ED attending but consulting specialty attending).

Acceptable documentation includes:

• Independent note by the attending

• Countersignature of resident’s note by physician’s name and a statement of his/her concurrence with care

(17_) For patients being transferred to other institutions, the notes will also include the reason for the transfer, the stability of the patient, and the acceptance by the receiving organization and the name of the responsible clinician during the transfer and documentation that the relevant patient information was sent with the patient.

(18_)Urgent care rendered for humanitarian reasons to a person who is not admitted must be made available to the practitioner or medical organization responsible for follow-up care.

(19_) ED Discharge: The supervising practitioner in consultation with the resident ensures that the discharge from the ED is appropriate. Any of the four types of residency supervision documentation is acceptable.

(a_) Documentation Requirements for Performing Invasive Procedures

(20_) Invasive Procedure involves puncture or incision of the skin or insertion of an instrument or foreign material into the body including, but not limited to, percutaneous aspirations and biopsies, cardiac and vascular catheterization, endoscopies, angioplasties, and implants.

Excluded from the…