36C24419R0074-022.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 174-01 July 24, 2017

HEALTH INFORMATION MANAGEMENT (HIM) AND PATIENT HEALTH

RECORDS

I. PURPOSE: To establish policy and procedures for the timely accurate completion of the patient health record and to describe the process for ensuring that all health records and patient record documentation are appropriately authenticated within the existing time frames required by the Erie VAMC in accordance with VHA Handbooks and various accrediting bodies in order to ensure quality and continuity of patient care.

II. POLICY: Under Title 44 United States Code (U.S.C.) 3102(1), Erie VA Medical Center, by statute, must maintain complete, accurate, timely, clinically-pertinent, and readily-accessible patient records which contain sufficient recorded information to serve as a basis to plan patient care, support diagnoses, warrant treatment, measure outcomes, support education and research, facilitate VHA performance improvement processes and legal requirements. VHA Handbook 1907.01, Health Information Management and Health Records and the Medical Staff Bylaws both provide guidelines and instruction to medical staff and health care personnel regarding content and completion of patient health records.

All inpatient and outpatient health record documentation must be present, authenticated and cosigned when applicable in the electronic health record by the end of all allied healthcare providers’ workday, but no greater than 24 hours from the time care was provided. Electronically stored and/or printed patient information is subject to the same medical and legal requirements as handwritten information in the health record.

A. The most current standards of The Joint Commission will also be followed, unless specifically otherwise stated.

B. The health record will be standardized with regard to content, creation, maintenance, management, processing, and expected quality measures. Electronic capture and storage of patient health information will be implemented to enhance access to patient data by health care practitioners and other authorized users.

Electronically stored and printed information is subject to the same medical and legal requirements as handwritten information in the health record.

C. The privacy and security of patient information stored in any media must be protected in accordance with, but not limited to: the Privacy Act of 1974 (5 U.S.C.

552a), the Freedom of Information Act (5 U.S.C. 552); Federal Information Security Management Act (44 U.S.C. 3541); Office of Management and Budget (OMB) Circulars A-123 and A-130; VA Directive and Handbook 6500 Managing

Attachment T

MCM 174-01, Health Information Management (HIM) and Patient Health Records

Information Security Risk: VA Information Security Program; Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules (Title 45 Code of Federal Regulations (CFR) 160, and 164); VHA Handbook 1605.1, Privacy and Release of Information; and The Joint Commission standards for privacy and security.

D. To maintain patient record security and confidentiality the Department of Veterans

Affairs (VA) Handbook 6500, regarding the Information Security Program must be followed.

III. RESPONSIBILITY:

A. Medical Facility Director. The medical facility director, or designee is responsible for establishing policies and procedures

B. The Chief of Staff, or designee, has ultimate oversight responsibility for health record timeliness, accuracy, and completion; however, the author of the entry is responsible for completing, authenticating, and correcting any health record deficiencies within the time frame defined by the facility policy or medical staff by-laws.

C. The supervising practitioner or attending physician is ultimately responsible for the accuracy of the health record for each patient under the physician’s care and for the preparation of a complete patient health record. The health care provider will document the medical record accurately and timely. Medical records must be completed within 30-days of patient discharge or are deemed delinquent.

D. HIMS will maintain the medical record in a manner so as to assure accessibility and permit prompt retrieval of information including statistical data. Assigned personnel will assist in the review of medical records and the collection of data to meet Medical Staff By-Laws and Rules and Regulations, VHA Regulations, and Joint Commission Standards.

E. The facility Privacy/Freedom of Information Act Officer or Alternate Officer will be the only designee authorized to amend a patient’s record after an official request for such amendment has been received from the patient and the process for approval/denial of the amendment has been completed as outlined in VHA Handbook 1605.1.

F. Every employee with access to patient records in any medium is responsible for proper handling of the patient records. Each employee is accountable for safeguarding patient confidentiality and privacy. Employees are required to take the annual VHA Privacy Policy and Security training and are responsible for the proper handling of the patient record. Failure to do so may result in disciplinary or other adverse action up to, and including, termination.

IV. PROCEDURES:

A. EMPLOYEE HEALTH RECORDS:

1. The health records of employees are under the management of human resources and, if on paper, will be stored in a separate and secure location from Veteran health records, and access should be granted only to those designated individuals with a need-to-know. If documented electronically in the Computer Patient Record System (CPRS), they will be secured utilizing Authorization Subscription Utilities (ASU) and the Veterans Health Information and Technology Architecture (VistA) Sensitive Flag will be set to “sensitive” to ensure that access to these health records is limited. All employee health records in CPRS will be designated as “sensitive.”

2. The health records of employees who receive care as Veterans are under the auspices of HIM and are maintained with other Veteran health records.

The electronic documentation of these health records will be secured by identifying them as “sensitive” health records in CPRS.

B. SECURING E-MAIL AND FACSIMILE TRANSMISSION:

1. E-Mail - According to VA Handbook 6500, Appendix D, electronic mail must be used for authorized government purposes and contain only non-sensitive information, unless the information is appropriately encrypted.

All encryption modules used to protect VA data must be validated by NIST to meet the currently applicable version of Federal Information Processing Standards (FIPS) 140-2.

2. Facsimile - Information received by facsimile (fax) is acceptable and may be included in the patient’s health record. Fax machine transmittals will not include information on drug, alcohol, Human Immunodeficiency Virus (HIV), or sickle cell anemia, unless the transmittal is directed to medical personnel, to the extent necessary, in a bona fide medical emergency.

3. A confidentiality statement will be attached to the cover page when transmitting individually-identifiable health information. For example, when transmitting outside VA: "This fax is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this fax does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please notify this office immediately at the telephone number listed above." NOTE: See VHA Handbook 1605.1, Privacy and Release of Information, for more information.

C. INFORMATION SECURITY:

1. VA requires that all individuals requiring access to VA information and information systems complete VA’s approved VA Privacy and Information Security Awareness Rules of Behavior training before such individuals are authorized access to patients’ health record and complete the training annually thereafter (see VA Directive 6500 and Handbook 6500 Appendix D, Risk Management Framework for VA Information Systems -Tier 3: VA Information Security Program, Appendix D, Department of Veterans Affairs National Rules of Behavior Introduction).

2. As custodian of the health record, only the Chief, HIM, or designee, can approve the physical removal of original health records from the treating facility.

3. Health records in file areas and other areas where health records are temporarily stored (clinic or treatment areas, record review areas, quality assurance areas, release of information, etc.) must be locked when designated authorized personnel are not present to ensure the security of the area and to ensure health records are not accessible to unauthorized individuals. Documents and health records show that the facility monitors physical access to information systems to detect and respond to incidents.

VA requires that facilities control physical access to information systems by authenticating visitors before authorizing access to facilities or areas other than areas designated as publicly accessible (see VA Handbook 6500, Appendix D).

4. Precautions must be taken by VA staff to ensure that patient health records on computer screens cannot be seen by individuals who do not have a legitimate need-to-know.

5. All patient-identifiable waste paper, or discarded materials, from any department must be shredded or disposed of in accordance with approved disposal policies and procedures. Locked containers or shredders must be provided in employee work areas for disposal of sensitive patient information. For more information refer to the VA Directive 6371, Destruction of Temporary Paper Records, which establishes VA policy to ensure that Personally Identifiable Information (PII) and other sensitive agency information contained in paper records is disposed of properly.

Paper shredders can be used to destroy flexible media, such as diskettes, once the media are physically removed from their outer containers.

D. CONFIDENTIALITY OF INFORMATION:

1. All staff with access to patient information in the performance of their duties needs to know their responsibilities in maintaining the confidentiality of VA sensitive information, especially patient information, by completing the annual Cyber Security and Privacy training.

2. Under 5 U.S.C. 552a, patient health records are confidential regardless of medium. The privacy of patient information must be preserved and the information must not be accessible to, or discussed with, any unauthorized persons, nor is the information to be discussed in public areas.

3. Every VA employee with access to patient health records in any medium is responsible for the proper use, disclosure, and handling of the patient health records (see VHA Directive 1605, VHA Privacy Program, and VA Directive 6500, Managing Information Security Risk: VA Information Security Program). VA employees are also accountable for safeguarding patient confidentiality and privacy; failure to do so will result in administrative action, up to and including, termination or other legal adverse action.

4. VA employees must transport patient paper health records within the health care facility using a secure means, such as locked bags. Patient names and Social Security Numbers (SSN) located on the outside of the paper health record must be protected from incidental viewing by the public while in transport. Patient health records must be in control at all times by the VA employee and not left unattended in any public area.

Where resources are not available, the patient may transport the patient’s own health record, as long as reasonable safeguards, approved by the Chief, Health Information Management (HIM), or facility Privacy Officer, are in place to ensure confidentiality and to maintain integrity of the health record. NOTE: VHA is minimizing the risk of identity theft and fraud by eliminating the unnecessary use of the SSN as an identifier, when possible.

E. SYMBOLS, ABBREVIATIONS, AND ACRONYMS. While there is no requirement by The Joint Commission for a list of approved symbols, abbreviations, and acronyms, if they are used in the health record, there will be an explanatory legend or standardized list available to decipher their meaning. There will be a list of unapproved symbols, abbreviations, and acronyms which will be made available to all those who make entries in the health record and to others who use health records in the course of their official duties. Symbols, abbreviations, and acronyms are not to be used when documenting final diagnoses and procedures on patients released from inpatient, ambulatory or outpatient services. When included in information provided to patients (e.g., consent forms), abbreviations and acronyms will be explained in language that the patient can understand. (see Appendix A)

F. LANGUAGE. All entries will be in English, and will conform to acceptable

English grammar. Documents that provide information to patients (e.g., consent forms) may include Spanish translations, when appropriate, provided that both Spanish and English translations are included in the document.

G. LEGIBILITY. Legibility refers to the quality of penmanship used when recording data, including a clear, written signature, as well as content and appearance of dictated, copied, or scanned information. Paper entries will be made in black ink to ensure permanent recording. NOTE: Handwritten entries are limited to those documents that current technologies cannot yet support.

H. SHADOW RECORDS. Shadow records will be limited or non-existent. (See

Appendix B)

I. FORM AND TEMPLATE MANAGEMENT.

1. The process for initiating, developing, and approving new electronic templates and overprinted paper health record documents will be established under the auspices of the Medical Record Committee’s health record review function.

2. All internally-generated forms and shared templates that become part of the health record will receive prior approval. Requests for new forms and templates are to be limited to those that can be developed in an electronic format.

3. As part of the health record review function, proposed templates will be reviewed for legal, policy, regulatory compliance, and ease of use.

Requests will be approved via the facility approval process prior to implementation

4. All components will reflect patient identifier information (full name and second unique identifier, such as Integration Control Number (ICN); when possible, the last four digits of the SSN are used instead of the full SSN), date of documentation, date of service, and facility name.

5. VHA paper forms for specific components of the record are no longer mandated; however, they are encouraged to be used as a guideline for developing electronic templates.

J. HEALTH RECORD OR HEALTH INFORMATION AVAILABILITY. In accordance to this policy, health information is always available, as needed.

1. For most cases where a patient is treated or seen at another VA medical facility, the Patient Data Exchange (PDX), Network Health Exchange (NHE) or Remote Data View (RDV), Remove Image View, VistA Web, or Register Once software will be used to expedite the transfer of needed health information between facilities. Scanned documents and images are only viewable through Remote Image View in VistA Imaging. Facilities will use the PDX encryption feature when transmitting data to other VHA facilities. If additional information is required, it may be copied and sent using overnight mail or secure fax machine when absolutely necessary.

2. Previous inpatient and outpatient health records will be made available upon specific request for treatment purposes or as support for claims benefits. When there is evidence that a health record exists at another VA medical facility or, at the VA Records Center and Vault (RC&V), the record will be ordered upon specific request.

K. AUTHENTICATION: Authentication demonstrates that the entry has not been altered. Authentication includes the time, date, signature or initials, and the professional designation of the practitioner (credentials).

1. Standardized and current electronic signature blocks for all authorized users based on the person’s class taxonomy file will be maintained. This ensures non-repudiation and that appropriate billing occurs.

2. Authentication functionality will include the identity and credential or professional discipline of the author, the date signed, and the time signed, if required.

3. As employees enter, leave, or transfer to a different position, the person class file and the title block will be edited to appropriately reflect job status.

4. All entries will be recorded and authenticated immediately after the care event or the observation has taken place to ensure that the proper documentation is available. This ensures quality patient care.

5. No medical staff member is to be required to authenticate entries that are not the staff member's own, in order to avoid filing a health record on an unfamiliar patient.

6. A supervising practitioner or medical staff member may, however, summarize a course of treatment based on existing patient health record documentation, or review a summary for consistency with existing patient health record documentation, if the original supervising

7. Practitioner or medical staff member responsible for the patient's care is no longer available to do so. In such cases, a notation will be made in the health record to the effect that the summarization (review) is being done from existing documentation in the absence of the supervising practitioner or medical staff member responsible for the patient's care and without personal knowledge of the patient. The completed summarization will be authenticated and dated by the medical staff member preparing the summary or the supervising practitioner.

L. SENSITIVE HEALTH RECORDS. Some specific health record types are deemed sensitive and may be maintained under direct supervision of the health information professional, or be flagged as “sensitive” in VistA or other facility computerized record repositories. These include, but are not limited to:

1. VA Veteran employee patient health records;

2. Regularly-scheduled Veteran volunteers;

3. Individuals engaged in the presentation of claims before VA, including representatives of Veterans’ Service Organizations, or cooperating public or private agencies or Administrative Tort Claims; and

4. Records involved in Administrative Tort Claim activities.

M. COMPUTERIZED PATIENT RECORD SYSTEM (CPRS). Computerized

Patient Record System (CPRS), VA’s electronic health record, contains Electronic Protected Health Information (EPHI). As such, CPRS is subject to the HIPAA Security Rule, which requires that covered entities guarantee the confidentiality, integrity, and availability to EPHI that they create, receive, maintain, or transmit.

N. COMPLETE AND INCOMPLETE HEALTH RECORDS. Patient health records will be timely, relevant, necessary, complete, and authenticated. Completeness implies that all required data is present and authenticated; all final diagnoses are recorded without use of abbreviations, and the transcription of any dictated information is completed, inserted, or uploaded into the health record.

1. The primary medium for documentation of all patient care activities within

VHA is the Computerized Patient Record System (CPRS). Patient health records, both hard copy and electronic, will be complete and include original authenticated documents relating to:

a. History and physical (H&P) examinations;

b. Operative reports;

c. Diagnostic and therapeutic procedures;

d. Consultations; and

e. Discharge summaries.

2. The Medical Staff rules and regulations define when the health record becomes delinquent; however, in no case can the time period exceed 30 calendar days. Completion of the health record as close to the date of discharge is strongly encouraged.

O. DECLARING A HEALTH RECORD. “Complete for Filing”. A health record is declared “Complete” for the purpose of filing when all required documentation is present.

1. If unusual circumstances prevent proper completion, the health record will be referred to the appropriate medical staff committee for review and completion.

2. When the appropriate medical staff committee declares an incomplete health record to be filed as complete, the portion(s) known to be incomplete, and the reason(s) normal completion could not be accomplished will be noted in the health record and this will be documented in an administrative progress note, and signed by the HIM professional, or designee.

3. A sample statement such as “Approved for filing incomplete on (date) by

Medical Staff Committee due to (reason)” may be used to note the health record as incomplete. This statement does not legally imply that the signer is validating the contents of the document, but is only administratively completing the health record. This statement will not be used on a routine basis to close health records due to the failure of an available physician to sign the documents.

P. STANDARDS OF ELECTRONIC NOTES.

1. Electronically stored or printed patient information is subject to the same medical and legal requirements as the hand-written information in the health record.

2. Entries will be accurate, relevant, timely, and complete.

3. Extraneous text needs to be omitted.

4. Succinct notes are more readable than verbose, lengthy notes.

5. Plagiarized data, without attribution, in the patient record is prohibited.

6. Standardized note titles facilitate the retrieval of specific patient information. Issues regarding note title standardization are part of the health record review function.

a. As nomenclature evolves, note titles will be standardized as proliferation of note titles makes retrieval difficult and cumbersome.

b. Appropriate note titles will be matched to the note content and the credentials of the author. NOTE: This enhances the ability to find a note quickly and easily.

7. Notes will be reviewed and signed promptly, as defined by facility policy.

8. Viewing unsigned notes is not allowed until such time as technology provides an audit trail of the note status. When viewing unsigned notes, there is a risk of clinical decision-making based on data that may be changed or deleted. Limited access to certain unsigned note titles (as determined by the VA medical facility) may be granted after review and approval by the appropriate medical staff committee to ensure that the viewing of these

Q. RETENTION, DISPOSITION, AND TRANSFER OF RECORDS:

1. The retention policy applies equally to both paper and electronic health records. VHA health record retention policy is 75 years after the last episode of care. Retention policies and guidelines are detailed in VHA Records Control Schedule (RCS) 10-1. Disposal procedures are set forth in 44 U.S.C. Chapter 33.

2. Health records will be stored at the treating VA medical facility for 3 years after the last patient activity. If space is an issue, active health records may be stored until retirement in National Archives and Records Administration (NARA) approved facilities or in facilities that meet the NARA guidelines. Previous inpatient and outpatient health records will be made available upon specific request for treatment purposes or as support for claims benefits. When there is evidence that a health record exists at another VA facility, or, at the RC&V, the record will be ordered upon specific request.

R. COPY AND PASTE, “CLONED NOTES,” IMPORTED TEXT, OBJECTS, etc.

(See Appendix C).

S. CLINICAL POSTINGS. At present, postings consist of crisis notes, clinical warnings, allergies, and Advance Directives. Crisis notes, clinical warnings, and Advance Directives are entered with an appropriately titled progress note and may be rescinded by changing the note title (for example, “Rescinded Advance Directive”). Allergies are entered from the cover sheet by going to the allergies or adverse reaction box and adding a new allergy. They can be removed by marking the allergy as entered in error. NOTE: For information on Patient Record Flags, go to http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2341.

This is an internal VA web site and is not available to the public.

T. AUTHORIZED ENTRIES.

1. Health care personnel who are directly participating in the patient’s treatment will make entries in the medical record.

2. Administrative personnel are authorized to make entries into the patient health record for the purpose of supporting patient care activities, such as non-VA care coordination and scanning of hard copy documents.

3. The patient health record needs to reflect honest and candid statements;

derogatory or critical comments are prohibited.

4. All authentications will include the identity and professional title/designation of the staff member performing the documentation in their electronic signature block.

5. Opinions requiring medical judgment must be documented or authenticated only by supervising practitioners or medical staff members, and other individuals who have been granted such clinical privileges within their scope of practice.

6. Individual employee names are not to be included in health record documentation unless the purpose is to identify practitioners for continuing care.

U. MEDICAL RECORD DOCUMENT SCANNING. (See Appendix D).

V. REVIEW OF MEDICAL RECORDS. (See Appendix E).

W. EVALUATION AND MANAGEMENT. (See Appendix F).

V. REFERENCES:

A. NIST Special Publication 800-53, Security and Privacy Controls for Federal

Information Systems and Organizations.

B. NIST Special Publication 800-66, HIPAA Security Rule.

C. 5 U.S.C. 552a, The Privacy Act of 1974.

D. 5 CFR part 2635, Standards of Ethical Conduct for Employees of the Executive

Branch.

E. The HIPAA Privacy and Security Rules, 45 CFR parts 160 and 164.

F. VA Directive 6609, Mailing of Sensitive Personal Information.

G. Records Control Schedule (RCS) 10-1.

H. VHA Handbook 1004.02, Advance Care Planning and Management of Advance

Directives

I. VHA Handbook 1004.04, State-Authorized Portable Orders (SAPO).

J. VHA Handbook 1605.1, Privacy and Release of Information.

K. VHA Handbook 1907.1 Health Information Management and Health Records;

Joint Commission Standards Accreditation Manual, Current Edition;

L. Joint Commission Hospital Standards Manual, Information Management

Standards;

M. 5 U.S.C. Section 522a (e) (5);

N. VA Directive 5021.

O. HIM Practice Brief #9: Monitoring Copy and Paste, October 2009.

P. Medical Staff Bylaws and Rules and Regulations

Q. VHA Handbook 1907.03

VI. FOLLOW UP RESPONSIBILITY: Chief, Health Information Management, Business Office Service.

VII. REPORTING REQUIREMENTS: See Appendix B-F for additional reporting requirements.

VIII. RECISSION: MCM 174-01, Copy, Paste and Template Use, dated June 7, 2011. This revision changes the title of this MCM. It also incorporates and rescinds the following policies:

A. MCM 174-04, Medical Records, dated September 15, 2008

B. MCM 174-07, Authorized - Unauthorized Abbreviations, dated August 6, 2009

C. MCM 174-08, Document Scanning, dated July 6, 2015

D. MCM 174-23, Review of Medical Records, dated October 2, 2009

E. MCM 174-27, Record Tracking, dated April 15, 2011

F. MCM 174-40, Policy For Evaluation And Management Guidelines, dated

February 18, 2011

(Original signed July 24, 2017) John A. Gennaro Medical Center Director

Attachments: A. Erie VAMC Unapproved Abbreviation List

B. Shadow Records C. Copy and Paste, “Cloned Notes,” Imported Text, Objects, etc.

D. Medical Record Document Scanning E. Review of Medical Records F. Policy for Evaluation and Management Guidelines

ATTACHMENT A

Erie VAMC Unapproved Abbreviation List

Do Not Use! Approved Alternative

OD, o.d., OS, o.s., OU, o.u. Use “right, left or each eye” as appropriate x3d Use "for three days"

Do NOT leave a blank space BEFORE a decimal (example .25)

Always use zero BEFORE a decimal when the dose is less than a whole unit.

Do NOT write a zero AFTER a decimal (example 2.0)

Always write whole numbers without a decimal (example 2)

U or u Write “unit”

IU Write “units”

MS

MSO

Write “morphine” Write “Morphine sulfate”

MgSO4, Mag, Mg Write “magnesium” or ‘magnesium sulfate” q.d. or QD Write “daily”

QOD Write “every other day” ug Write “mcg” cc Write “ml” or “milliliters” or preferably “mL” sq or sc Write “subcutaneously” or “subcut” tiw Write “3 times weekly”

AD, a.d., AS, a.s., AU, a.u. Use “right, left or each ear” as appropriate

ATTACHMENT B

SHADOW RECORDS

I. PURPOSE: To ensure compliance with The Joint Commission standard RC.01.01.01 and to establish a process to track the location of all shadow records. Joint Commission states the medical record should contain complete information regarding the patient’s care and treatment and should promote continuity of care among providers.

II. POLICY: The HIM Chief will be aware of any use of shadow records and, with the advice of the Facility Records Manager and the Medical Record Review Committee, will determine the need to continue the use of any shadow health records and document such action in the committee minutes. The need for shadow records should be limited or non-existent.

III. DEFINITIONS: Shadow files are defined as duplicate records that are kept for the convenience of a department or healthcare provider. Shadow files can also be original data that is kept in the service area with a summary note or interpretation documented in the Computerized Patient Record System (CPRS).

IV. RESPONSIBILITIES: Service Lines are responsible in ensuring shadow records are not maintained in their areas. Any use of shadow records will include a policy to address the privacy, security, and destruction of shadow records that may not be under the control of the HIM Chief.

V. PROCEDURES: If Service Lines feel that a Shadow File system is necessary for the service area to continue, approval must be granted by HIM and/or the Records Manager.

A master list of shadow files will be maintained with documentation of location, security and retention guidelines.

MCM 174‐04, Health Information Management (HIM) and Patient Health Records

ATTACHMENT C

COPY AND PASTE, “CLONED NOTES,” IMPORTED TEXT, OBJECTS, ETC.

I. PURPOSE: To establish a policy and procedure and to assign responsibility for copy and paste functions in progress notes within the Computerized Patient Record System (CPRS). This policy applies to Erie VA Medical Center (EVAMC), to include all affiliated Community Based Outpatient Clinics.

II. POLICY: Erie VA Medical Center (EVAMC) is committed to creating an environment that promotes and fosters the use of the Computerized Patient Record System (CPRS) by defining policies, objectives and responsibilities for "copy and paste" use in documents related to patient care.

III. RESPONSIBILITY: The Chief of Staff will be responsible for overall compliance with this directive. Service Chiefs are responsible for compliance in their respective areas.

Reviewers of the record will include, but not be limited to, Health Information Management, the Compliance Officer and Quality Management staff. All employees are responsible for referring any case of questionable or inappropriate copying, pasting or template use to the author of the note and the Health Information Management Chief.

IV. PROCEDURES:

A. The electronic functions that allow importing of text from other sources by copy and paste or use of objects are powerful tools; however, this functionality must be used with caution and according to strict and enforceable policy. Clinical, 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 was documented.

B. Copying information from other documents in Veterans Integrated and Systems

Technology Architecture (VistA) or CPRS is unnecessary duplication of information that does not assist those reading the record. Repeating information does not provide any advantage, but instead makes reading the charts more difficult and time consuming; copied portions of notes and other data is overwhelming to the reader and diminishes the remaining information within the note.

C. This policy will ensure that the elimination and/or judicious use of this electronic functionality at the Erie VA Medical Center.

D. Providers are responsible for the total content of their documentation, whether they originated, copied, pasted, imported, or reused the content.

1. Risks of Copying Text Using the copy functionality in an Electronic

Health Record (EHR) system pose risk to documentation integrity, including:

a. Inaccurate or outdated information that may adversely impact patient care and safety.

b. Inability to identify authors or their individual interpretations.

c. Inability to identify when the original documentation was created.

d. Inability to accurately support or defend diagnostic or procedural codes for billing of professional or technical services.

e. Propagation of false information.

f. Internally inconsistent progress notes.

g. Unnecessarily lengthy progress notes.

h. Potential for copy/pasting information into the wrong patient’s record or to the wrong encounter.

2. Rules for Importing and/or Copying Text:

a. Never copy the signature block into another note.

b. Never copy data or information that identifies a healthcare provider as involved in care that the healthcare provider is not involved in.

c. 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.

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

e. Use the functionality of importing data objects into progress notes and other documents judiciously. Policy states 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.

f. Never copy information from publications.

g. Never import the patient demographic (name, address, phone number, NOK, etc.) information into a progress note since it is immediately available at all times by clicking on the patient’s name.

h. Do not copy data or information from one patient to another, especially when patients are seen or treated for the same diagnosis.

3. Accountability:

a. The author is liable for the content of copied items within the notes he/she authenticates. As part of the health record review function, use of copy and paste functionality must be monitored. When violations occur, findings must be reported to the appropriate medical staff committee for disciplinary or other adverse action.

NOTE: Criminal charges may be filed when in violation of Federal law.

ATTACHMENT D

MEDICAL RECORD DOCUMENT SCANNING

I. PURPOSE: To establish policies, procedures, objectives, and responsibilities for receiving and either scanning of medical record documents (paper or electronic sources) and/or importing images into patient electronic records for care provided to our veteran population.

II. POLICY:

A. Only documents (regarding care of the patient) which cannot be entered by conventional technology in the Computerized Patient Record System (CPRS) will be scanned. (Examples of scanned documents may include: Advance Directives, progress notes containing drawings, patient-signed clinical documents, flow sheets, non-VA medical records including Fee Services.)

B. All documents from external sources must be in compliance with VHA Handbook

1907.01 prior to scanning, especially in reference to only scanning authenticated documents.

1. For compliance reasons images entered into Vista Imaging must not be misconstrued as a consultation to read and interpret Outside Films, AND must not violate any contractual agreements with the vendor (if VA paid) or the non-VA provider.

2. Excluding Fee Services, other non-VA documents allow either the primary care provider or a specialist in the subject matter to enter an Outside Medical Record note entered in CPRS in lieu of or in addition to the scanning or importing of images. (The note should indicate the provider has reviewed the images/documents and is in agreement with their content.)

C. The Medical Record Review Committee will approve the categories and types of images and documents to be imported or scanned into CPRS.

1. Only those approved will be allowed to be entered.

2. A standardized naming convention for note titles will be approved through the Forms Committee in order to assist in differentiating between VA and non-VA records

III. RESPONSIBILITY

A. The Medical Record Review Committee will be responsible for oversight of Vista Imaging/Document Scanning.

B. Services are responsible for forwarding documents to be scanned by the centralized scanning unit (HIMS) on a daily basis. Documents are to be identified with name, last four of social security number, and flagged for scanning. All fee-basis documentation must be identified as such to include information that identifies consults.

C. Clinicians are responsible for reviewing outside documents. Clinicians will sign and date document cover sheet from outside sources to indicate review and will forward documents requiring scanning to the File Room.

D. VHAERI Progress Note Error will be notified through an Outlook secure message of scanning corrections and title discrepancies.

E. The HIMS Chief or designee will provide oversight and direct supervision to the File

Room scanning clerks. The HIMS Chief or designee will monitor scanning backlog and scanning errors for correction.

F. The HIMS Chief or designee will manage the process of scanning approved documents for the Medical Center and ensure documents are scanned into CPRS within 2 work days. Advance Directives will be scanned within 24 hours. The HIMS Chief or designee will ensure weekly quality assurance checks are performed by file room staff.

G. On a monthly basis the HIMS Chief or designee will provide the Medical Records

Review Committee with quality assurance findings and corrective actions taken.

H. All Medical Records Clerks will receive scanning training from Clinical Informatics.

After demonstrating a thorough understanding of scanning rules and requirements the clerk will receive the necessary options to scan records independently.

I. The Chief, HIMS or designee of the scanning unit is responsible for ensuring that current procedures are followed. Quality checks will be conducted to ensure that trained employees are meeting criteria.

IV. PROCEDURES

A. Definitions: Scan/Scanning – The capture of data via imaging/pictorial technolog

B. On a daily basis, clinicians will forward documents to the File Room for scanning.

The scanning cover-sheet will be attached to the outside of the envelope. The file room staff will scan the document and attach the image to the appropriate progress note in the electronic medical record. Paper documents, used at this facility, identified as template-able will be developed into electronic form to eliminate the need for scanning.

C. For Clinically pertinent documents generated outside the VA, the clinician will review the records and complete the cover sheet.

D. The Medical Support Assistant will enter an administrative note with the name of the outside facility and dates of services for the records the provider has reviewed.

MSAs will indicate on the scanning-cover sheet the note title and date to which the scanned image should be attached.

E. Centralized scanning will be performed in the HIMS, scanning department. HIMS is responsible for scanning paper documents generated within the Erie VA Medical Center, fee basis records and outside non-VA records as well as numerous administrative documents.

F. Quality Assurance:

1. Concurrent QA:

a. Once the document(s) has been scanned, the image will be checked for the overall quality and visibility of the document and for the correct or best position of the document in VistA Imaging Capture prior to saving the image. The image will also be reviewed to ensure correct patient and that all pages are scanned. The responsible person scanning the document will perform this process before reaching retrospective QA.

b. The second quality check of the scanned document must be verified by logging into VistA Imaging Display to confirm the documents accessibility. The responsible person scanning the document will perform this process before reaching retrospective QA.

c. Scanning technicians will create an addendum to their note before an error can be deleted and rescan the document correctly.

2. Retrospective QA:

a. Audits must be performed on every single document after a new employee begins scanning without direct supervision, until 100 scans/packets of the same type of documents have been scanned error free (following initial training). The document types to be scanned are VA Administrative, VA Medical and Non VA Care.

b. Once the new employee has scanned 100 packets each of VA

Administrative, VA Medical, and Non VA Care Medical Records error free the HIMS, Chief and employee will both certify that they are proficient in each document type.

c. The employee responsible for the retrospective QA of scanned documents will identify and review 10% of randomly selected documents scanned by each employee using the QA tool in VistA Imaging.

d. The image is reviewed for quality, clarity, completeness, correct patient chart, and legibility.

3. Document Destruction

a. Original documents must be retained until a 100% QA of every document has been done by the capture technician and the 10% sample QA Review has been completed by a third party. As an additional safeguard, original documentation must be kept for 2 weeks.

b. After the two week safeguard has passed the original documents/input data may be destroyed in accordance with NARA retention schedules Record Control Schedule (RCS)-10-1 or General Record Schedule (GRS).4.3 once data has been confirmed in VistA Imaging.

G. Scanning:

1. Obtain required signatures prior to scanning. (Note: Documentation from outside sources (Fee Services) also requires signatures and must be obtained by the Fee staff prior to payment and scanning.)

2. The scanning of all patient documentation (both inside and Non-VA documents) should be done as soon as possible from receipt, but no later than 5 business days.

3. Scanning will be completed by the HIMS Scanning Unit unless there is an impact on continuity of patient care that necessitates decentralized (point of care) scanning.

a. The decentralized areas must follow all procedures, timeframes and quality assurance guidelines as the HIMS Scanning Unit.

b. The HIMS Medical Records Team Supervisor will maintain a list of where facility scanning/document importing is performed.

c. The person(s) scanning documents as part of Consult Package will be required to have additional training by HIMS staff to assure adequate steps are taken to also close the consult correctly.

4. Services doing point of care scanning/importing should have a statement of such in both their employee position descriptions as well as in their performance measures.

5. After scanning each scanned "set" should be stamped 'SCANNED' and initialed and dated by the scanning personnel as a check to verify they have processed that set and to ensure that the document(s) has passed the employee level quality checks.

6. Scanned documents are subject to the same medical and legal requirements as handwritten information in the medical record.

ATTACHMENT E

REVIEW OF MEDICAL RECORDS

I. PURPOSE: To establish policy for the review of medical records for completeness.

Completeness implies that all required data is present and authenticated AND all final diagnoses are recorded without use of abbreviations.

II. POLICY: It is this medical center’s policy that patient records are timely, relevant, necessary, complete, and authenticated.

A. The Chief of Staff, or designee, has ultimate oversight responsibility for health record timeliness, accuracy, and completion.

B. The author of entry is responsible for completing, authenticating, and correcting any health record deficiencies.

C. The Health Information Management Section (HIMS) is responsible for creating and monitoring systems to ensure accurate, timely, and complete health records, in accordance with VHA policy and the Joint Commission.

D. The Medical Record Technician, Record Reviewer is responsible for conducting the daily, monthly and quarterly reviews determined as needed by the Medical Record Review Committee (MRRC) and submitting all reports to be reviewed.

E. The Medical Record Review Committee and the Compliance Officer will review findings, make recommendations to the service and Medical Executive Committee and/or take corrective action as appropriate.

IV. PROCEDURE:

A. The following monitors will be performed by HIMS and status reports will be reported monthly to MRRC:

1. Following discharge, the Medical Records Technician, Record Reviewer will perform a qualitative and quantitative analysis of patient records identifying documentation deficiencies. Review will include the presence and authentication of, at least, the history and physical examinations, operative reports, diagnostic and therapeutic procedures, consultations, and discharge summaries. Authors will be contacted to correct any health record deficiencies. Delinquency patterns will be reported to MRRC. A record will be considered delinquent when deficiencies cannot be corrected within 30 days post discharge. The Joint Commission Medical Record Statistical Form will be completed monthly;

2. Monitor unauthenticated electronic documents to include: no notes where an encounter exists in VistA, unsigned/uncosigned progress notes, addenda, additional signers, and doctor’s orders;

3. Review timeliness of dictation and authentication of history and physicals, discharge summaries, and operation reports. Provider specific reports will be sent via memo from the Chair of the MRRC to the Supervisor of the individual provider and will be made part of the credentialing and privileging files;

4. Monitor the use of unapproved abbreviations including trends in providers using the unapproved abbreviations;

5. Monitor timeliness, accuracy, and upload process of transcribed documents including the use of speech recognition software;

6. Monitor quality assurance and the backlog of document scanning.

B. HIMS will assist MRRC with quarterly reviews of inpatient and outpatient programs, Community Living Center and Behavioral Health Programs as appropriate utilizing the Joint Commission standards.

C. MRRC will review monitors and take corrective action and/or make recommendations as appropriate. Findings will be shared and recommendations forwarded to the Medical Executive Council (MEC).

ATTACHMENT F

POLICY FOR EVALUATION AND MANAGEMENT GUIDELINES

I. PURPOSE: To establish and outline the Health Information Management (HIMS) policy for the facility’s use of Evaluation and Management Guidelines. This policy establishes the 1995 Evaluation and Management Guidelines as the official guidelines used by Erie VA Medical Center for Evaluation and Management coding and documentation.

II. POLICY:

A. It is this Medical Center’s policy to use the 1995 Evaluation and Management Guidelines in all clinical areas of the medical center and outlying CBOC’s.

B. All clinicians will use 1995 Evaluation and Management Guidelines to perform clinical documentation.

C. All coding staff will use 1995 Evaluation and Management Guidelines to assign the appropriate level of Evaluation and Management code to each billable encounter.

A. The Health Records Administrator has the overall responsibility to implement 1995 Evaluation and Management Guidelines for both the clinical staff and the coding staff.

B. The clinicians have the overall responsibility of ensuring that all documentation utilizes the 1995 Evaluation and Management Guidelines.

C. All medical center coding staff are responsible for ensuring that they are utilizing the 1995 Evaluation and Management Guidelines when filling in the Evaluation and Management Calculator portion of QuadraMed on all billable encounters.

D. The Health Records Administrator has the overall responsibility for ensuring that monitoring and auditing processes utilize the 1995 Evaluation and Management Guidelines.

IV. PROCEDURES: The following procedures govern the internal accountability for documentation and E&M services provided:

A. The medical record should be complete and legible.

B. The documentation of each patient encounter should include:

1. The reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

2. Assessment, clinical impression or diagnosis;

3. Plan for care; and

4. Date and legible identity of the observer.

C. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

D. Past and present diagnoses should be accessible to the treating and/or consulting provider.

E. Appropriate health risk factors should be identified.

F. The Veteran’s progress, response to and changes in treatment, and revision of diagnosis should be documented.

G. The ICD and CPT codes reported on the insurance claim form for billing statement must be supported by the documentation in the medical record.