S02_Attachment_17_Medical_Records.doc

Attachment 17 – 36C24919R0003

POLICY MEMORANDUM

VA Medical Center

1030 Jefferson Avenue

Memphis, TN 38104

Number:

136-39

Dated:

April 6, 2018

Expires:

April 30, 2023

Title:

MEDICAL RECORDS

1. PURPOSE: To inform all clinical providers of the policy of the VA relating to the quality and confidentiality of medical records and specify documentation requirements.

2. POLICY:

a. The policy of this Medical Center is to provide an electronic medical record as documentation of the medical care provided by our employees. In instances where a hard copy document must be maintained a non-electronic medical record will be established. It is the goal of this medical center to have a completely electronic medical record therefore paper documents should be rare and only exist when there is no other option available. Existing policies and procedures pertaining to paper medical records shall apply to computer generated medical records, including but not limited to, medical record delinquencies and deficiencies, responsibility for accuracy, authority to make entries, and making changes in the medical record.

b. Medical records regardless of the medium are confidential in nature and will be safeguarded from unauthorized disclosure at all times. Records may not leave this Medical Center except in response to a court order. Information therein will not be accessible to or discussed with unauthorized persons. The privacy of medical records will be preserved and the record content will be inaccessible to patients. (Exception - On official written request under the Privacy Act, contents may be released to a veteran-patient).

c. Record Retention policy applies equally to both paper and electronic 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. Records will be stored at the treating VHA facility for three years following last patient activity. Paper records may be retired to a Federal Records Center.

d. The VA will maintain complete accurate, relevant and timely medical records which contain sufficient recorded information, written in sequence of events, to support the diagnoses and warrant the treatment and end results. The medical record content requirements of the Joint Commission will be met.

e. Complete, concise, legible and accurate medical records will be maintained. All entries will be in English. If data is dictated, the transcribed entry or document will contain the dates of dictation and transcription. Each page of the medical record should reveal or contain as a minimum the patient's full name and entire social security number.

(1) 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, and/or scanned information. Patient safety and the general usefulness of the paper record depend on the legibility and the readability of the entries. Paper entries must be made in black ink to assure permanent recording. Handwritten entries are being phased out and need to be limited to documents technology cannot yet support.

(2) Scope of Documentation:

(a) The health record needs to reflect honest and candid statements; derogatory or critical comments are to be avoided. Individual employee names are not to be included in health record documentation unless the purpose is to identify practitioners for continuing care.

(b) Emphasis is placed on relevant day-to-day entries. Timely entries must be made on appropriate documents following examination and treatment as specified in VHA and facility policies.

(c) Each patient event must include or provide reference to: The chief complaint and/or reason for visit and, as appropriate, relevant history, examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the health care professional; and identification of appropriate risk factors.

(d) The scope of documentation must be comprehensive enough to: Provide continuity of care; be concise and complete; reflect any treatment for service-connected condition(s), including agent orange, ionizing radiation, military sexual trauma or external contaminants; support reported workload; and bill for services.

f. Medical symbols and abbreviations will be used in the medical record only when the Medical Record Committee has approved them with the concurrence of the Clinical Executive Board and the Chief of Staff. There will be an explanatory legend of accepted symbols and abbreviations and each abbreviation or symbol will have only one meaning. The list of unapproved abbreviations is published in Policy Memorandum 11-50 and will not be used in the medical record. Symbols and abbreviations are not to be used when documenting final diagnoses and procedures on patients released from inpatient and ambulatory and/or outpatient services.

g. Standards for Documentation:

(1) Joint Commission standards regarding documentation pertinent to care and treatment records apply to all records regardless of the medium.

(2) The primary medium for documentation for all patient care activities within VHA is Computerized Patient Record System (CPRS).

(3) Opinions requiring medical judgment must be documented or authenticated only by medical staff members, and other individuals who have been granted such clinical privilege within their scope of practice.

(4) Students are permitted to enter progress notes but these notes are not a substitute for the requirement of documentation by the primary provider.

(5) Health care practitioners must document according to regulatory standards and generally accepted documentation practices for completeness and timeliness.

(6) Health care practitioners involved with the patient’s care must enter documentation of each event of a patient’s care into the health record.

(7) The practitioner who treats the patient is responsible for documenting and authenticating the care provided.

h. Information contained in the medical record must be accurate.

(1) If an entry or a portion of a paper entry is found to be incorrect, a single line will be drawn through the incorrect information without obliterating the original entry. The initials of the person making the correction and the date of the correction will be placed above the incorrect data. The correct information will be added, if appropriate. A note will be made to indicate why the correction is necessary and the notation will be signed and dated by the responsible practitioner. If a supplemental or corrective statement is needed, it should be entered in the record chronologically by date of the entry. An exception to the above procedures concerns amending medical records pursuant to a Privacy Act request.

(2) If an error is made in the electronic record, it may be edited at any time prior to the electronic signature. Once electronically signed, corrections must be made utilizing an addendum.

(3) If data is entered electronically on the wrong patient, an addendum will be done by the author indicating "data entered on wrong patient's record". The Chief of Health Information Management (HIMS) or designee must be notified by encrypted e-mail or phone call so the note can be deleted (retracted) to prevent problems with clinical decisions based on incorrect data. A document that is written for the correct patient, but is erroneous in content must also have an addendum to indicate the need for deletion as above. This requires entry of a new document with the correct information.

(4) Standards of Electronic Notes:

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

(b) Entries must be accurate, relevant, timely, and complete.

(c) Extraneous text needs to be omitted.

(d) Succinct notes are more readable than verbose, lengthy notes.

(e) Plagiarized data in the patient record is prohibited.

(f) Standardized note titles facilitate the retrieval of specific patient information. Issues regarding note title standardization are part of the health record review function. All locally approved note titles must be mapped to the national note titles. NOTE: As nomenclature evolves, note titles will be standardized. Proliferation of note titles makes retrieval difficult and cumbersome.

(g) Appropriate note titles must be matched to note content and the credentials of the author. This enhances the ability to find a note quickly and easily.

(5) Copy and Paste (Cloned Notes):

(a) The electronic function of copy and paste is a powerful tool; 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 obtained historical information, performed an exam, and/or documented a plan of care when the author did not personally do it.

(b) Copying information from other documents in 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 dwarfs the remaining information within the note.

(6) Copy and paste tenets:

(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. Data copied into the record needs to be specific and pertinent to the care provided.

(d) A note may include limited key data that may have been recorded elsewhere.

(7) Accountability:

(a) 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 Medical Staff Committee for disciplinary or other adverse action. NOTE: Criminal charges may be filed when in violation of Federal law.

(b) Failure to comply with these standards may be deemed a violation of the:

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

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

(c) Disciplinary action may be taken if violations of these 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.

i. The medical record will contain a current problem list. This problem list will be maintained electronically and initiated by the health care practitioner by the third visit. The following items are either maintained on the problem list or are viewable in the medical record: a summary list of significant past surgical procedures, past and current diagnosis, drug allergies, and current and recent medications.

(1) 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 reports tab.

(2) 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.

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

(4) The physician 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.

(5) Outpatient progress notes must contain the following components: Presenting problem(s) (reason for visit); history and objective data relevant to the presenting problem(s); assessment of the problem(s); treatment plan for the problem(s); diagnosis(es) treated during an encounter or that require further treatment; reason (i.e., the medical necessity) for ordering tests, consults, or changes in medications; and follow-up treatment and patient instructions.

j. Resident Supervision. The patient record must document adequate supervision of residents in the care of patients according to the most current VHA policy (see VHA Handbook 1400.01, for additional information).

k. Supervision of Associated Health Trainees. The patient record must document adequate supervision of Associated Health Trainees in the care of patients according to the most current VHA policy (see VHA Handbook 1400.04, for additional information).

l. External source documents may be maintained as part of the patient’s VHA permanent health record at the practitioner’s written request. Practitioners must indicate which documents need to be retained and limit this to pertinent, present, and/or continued care. These documents should be limited to summaries of care or procedures performed not to exceed five documents of each. A summary progress note written by an appropriate clinician after a review of the external source documents may be used in lieu of filing and/or scanning any external source documents. Any documents or information filed, maintained, or scanned into a patient’s health record, including external source documents, are deemed to be part of the patient’s VA health record.

m. All internally generated forms and shared templates that become part of the health record must receive prior approval from the Medical Record Committee. Requests for new forms and templates are to be limited to those that can be developed in an electronic format. New paper forms will not be approved. Templates must be reviewed for legal, policy, regulatory compliance, and ease of use. Only approved abbreviations will be allowed in the template.

n. During computer down time procedures must be followed to insure documentation for continuation of care. See Attachment A for procedures.

3. RESPONSIBILITY:

a. Clinical staff members are responsible for appropriate documentation in the medical record.

b. The Medical Record Committee is responsible for ensuring compliance with VA and Joint Commission regulations regarding medical record content.

c. Health Information Management employees are responsible for reviewing medical records and reporting problems. A multidisciplinary team will assist in medical record reviews.

d. Outpatient clinic health care providers will be responsible for updating the Problem List, as needed. When the practitioner identifies new medical/health care problems, he/she should so indicate on the encounter form for that visit and will add this information to the electronic Problem List.

e. The Medical Record Committee is responsible for the review of delinquent records. If the provider is no longer associated with the medical center, the committee will make appropriate recommendations to the Chief of Staff for declaring a record complete. The Chief of Staff, upon approval of the Clinical Executive Board, can order the filing of an incomplete medical record.

f. The Attending Physician is ultimately responsible for the accuracy of the health record for each patient under the physician’s care. The Chief of Staff, or designee (equivalent), has oversight responsibility for health record timeliness, accuracy, and completion.

4. PROCEDURE:

a. The Medical Record may be maintained as a paper record, a computer based record or a combination of both paper and electronic mediums. However, new paper documents should be created only when essential to the care of the patient and cannot be created in electronic format.

b. Contents of Medical Records. Medical records must be complete and include original authenticated documents relating to the patient's chief complaint; past medical/surgical history; family history; history of present illness; physical examination on admission and provisional diagnosis; treatment plan; physical, psychological and social assessment; medical certificate of the hospital application; clinical laboratory, pathology, and x-ray findings;

descriptions of operations performed; documentation of informed consent, advanced directives when appropriate; adequate progress notes; consultations and other special reports; diagnostic and therapeutic orders; final diagnoses; condition on discharge; follow-up recommendations and instructions; competency opinion for psychiatric patients; and an appropriate summary of the period of hospitalization. The name of the attending physician should be clearly identified in the medical record on the first order. In death cases, in addition to a copy of the death certificate, the record will include the original autopsy protocol if a postmortem examination was performed. The medical record format approved for use at this Medical Center is contained in Attachment B.

c. Signatures:

(1) Each entry in the medical record will be authenticated as soon after preparation of the entry as possible. Authentication will consist of time, date and signature, and title of the physician or other responsible member of patient care team making the entry.

(2) Any entry using initials will be substantiated by at least one entry with the signature of the individual made during the episode of medical care.

(3) A rubber stamp signature will not be used in lieu of an original signature.

(4) A medical student's`, history and physical (H&P), and final summary must be countersigned by the physician responsible for the case. A co-signed student note cannot substitute for a resident's or primary care provider's note.

(5) Attending medical staff members will countersign the History and Physical (H&P), Discharge Summary and any Operative Reports. The attending physician will also write an admission note and enter periodic notes in the medical record as needed to document ongoing involvement in the inpatient care process. At least once daily, there should be documentation regarding the attending involvement in Resident Care. Attending physician documentation should comply with requirements listed in the Medical Center Policy Memorandum 11-27.

(6) An electronic signature is the accepted method to authenticate medical records such as Progress Notes, Discharge Summaries, Doctors’ Orders and other electronic documents. A complete electronic signature will consist of the caregivers name, credential title (MD, RN, etc.), date and time of the entry.

d. Electronic Signatures:

(1) Local policy must provide adequate security measures identifying those users who can document in the health record and verifying the authenticity of user electronic signatures. An author is responsible for the sole use of the author’s access and verify codes. The person whose signature the electronic code represents must sign a yearly statement that this individual is the only one who will use it. An annual agreement is signed that it is related to system access, not specifically to a user’s electronic signature.

(2) Currently, there are three types of signatures in the electronic health record:

(a) A "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.

(b) A "co-signer" is the attending, staff, or supervising clinician. A co-signer may also be a service chief or designee as defined by the organization's bylaws and/or policies. A co-signer may edit and authenticate a document if the author has not already signed the document.

(c) “Identified signer" and "additional 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 a co-signature. This nomenclature in no way implies responsibility for the content of or concurrence with the note. NOTE: “Identified signer” is nomenclature used by CPRS, VistA, and TIU; “additional signer” is nomenclature used by GUI.

e. Content:

(1) Initial Assessment/Reassessment.

(a) Members of the patient's care team must document initial assessments. Contents must meet the applicable Joint Commission requirements. See Medical Center Policy Memorandum 11-02 for specific requirements.

(b) An initial screening and/or assessment (i.e. nutrition, nursing, social work, functional, cultural, occupation and physical therapies, psychosocial, spiritual, legal etc.) must be completed within 24 hours of admission.

(c) Educational needs, preferences, abilities, and readiness to learn are assessed on admission. The education process is interdisciplinary, as appropriate, to the care plan. Documentation of education related to nutrition, nursing, and rehabilitation is required.

(2) History and Physical Examination.

(a) A complete H&P examination will be performed and documented for each patient within 24 hours of admission. A H&P, whether for admission or surgery, that is over 30 calendar days old is not acceptable and a new H&P must be documented.

(b) When, within a 30-day period, an inpatient is readmitted for the same or a related condition, an interval history and physical exam will suffice. The interval history and physical will be entered on the progress notes and will contain:

1 A statement that the previous history and physical examination has been reviewed; and

2 A statement that there are pertinent additions to the history and/or subsequent changes in the physical findings which will be specified; or

3 A statement indicating there is no change noted in the review of the previous history and physical examination.

(c) In all cases where surgery is performed, the medical record will document a current, thorough physical examination prior to the performance of surgery. When the H&P is done within 30 calendar days prior to surgery, the prior H&P may be used, but an interval note must be completed indicating: The H&P is still accurate; an appropriate assessment was completed prior to surgery (within 24 hours) confirming the necessity for the procedure is still present; the patient’s condition has not changed since the H&P was originally completed; or any changes are documented.

(d) A patient remaining on inpatient status for a year or longer will be given an annual examination.

(e) H&P examinations must be completed by clinical staff as delineated in facility By-laws or by scope of practice.

(f) In an emergency, when there is no time to record the complete H&P examination, a progress note describing a brief history and appropriate physical finding and the pre-operative diagnosis must be recorded in the record before surgery.

(g) An initial treatment plan, documented by the clinician, as part of the physical exam must be established on all patients within 24 hours of admission on acute care patients.

(3) Progress Notes

(a) Progress Notes facilitate the communication among disciplines concerning the patient's care. Members of the patient care team must 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. Progress notes must give a pertinent chronological report of the patient's course, and may include, but are not limited to: a change in diagnosis(es), a change in condition, a patient's leave of absence, and any justification for patient limitations. Progress Notes should be signed within seven (7) days.

(b) Clinical care must be documented in a progress note by the respective clinical staff as defined by their scope of practice.

(c) Documentation in the progress notes is required when there is a history of allergies, adverse reactions, or other conditions. The appropriate title must be used to trigger patient postings, as in Clinical Warning Advance Directive (CWAD).

(d) Inpatient progress notes must be written and signed in the computer at the time of observation, at least once daily for patients in an acute care status or at a frequency appropriate to the patient's condition., Progress notes should be in sufficient detail to permit continuity of care and transferability.

(e) Supervision of Resident Care for inpatients and outpatients must be documented by a supervising practitioner according to VHA Handbook 1400.01 and Medical Center Policy Memorandum 11-27.

(f) The admission progress note must include: The type of admission, i.e. elective, emergency; chief complaint; a brief summary of the patient's condition; and a tentative or differential diagnosis.

(g) Reassessments are completed at regularly specified intervals as outlined in Medical Center Policy Memorandum 11-02.

(h) The patient's actual or potential for suicidal behavior must be documented in a progress note. See Medical Center Policy Memorandum 116A-1 for management of patients on suicide precautions.

(i) the appropriate licensed health care professional must clearly document the necessity for each restraint or seclusion order in the progress notes. See Medical Center Policy Memorandum 118-01 for specifics.

(4) Discharge Summary:

(a) The discharge summary must be prepared for all releases from VHA care, including deaths. Transfers to other levels of care such as: VHA domiciliary care, VHA nursing home, or other VHA medical centers, must be documented by a discharge summary.

(b) Responsibility for the preparation of the discharge summary and for its content rests exclusively with the member of the medical staff having primary care responsibility for the patient. The treating specialty from which the patient is discharged is responsible for completing the summary.

(c) The summary must be documented prior to discharge, or within 24 hours of death and irregular discharge. When the discharge summary is completed more than 24 hours prior to discharge an addendum is required if over five (5) days.

(d) If not the author, the attending physician must review the summary, make appropriate edits, and indicate approval by signature.

(5) Summaries must be prepared as follows:

(a) Diagnosis. List the principal diagnosis; i.e., that condition established after study to be chiefly responsible for the admission of the patient to the hospital for care; then, in order of clinical importance, list all other diagnoses for which treatment was given. Diagnoses must include post-operative complications or infections and drug or serum reactions. All diagnoses need to include a site and etiology, when applicable, and must be stated in full, without symbols and/or abbreviations, and in accordance with the latest edition of International Classification of Disease (ICD).

(b) Psychiatric Diagnoses. Diagnoses must be stated in accordance with the latest edition of Diagnostic and Statistical Manual of Mental Disorders (DSM).

(6) Operations and surgical procedures must be stated in full, without symbols and/or abbreviations, and in accordance with the latest edition of CPT and/or ICD Procedural Index. The site involved and the procedures performed must be stated. The listing must include all operations, diagnostic and therapeutic procedures, and the date performed. All procedures need to be documented in the text of the summary.

(7) The body of the Discharge Summary must include:

(a) The name of the attending physician responsible for patient’s care and primary physician, if applicable;

(b) Reason for admission (principal diagnosis; i.e., the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital);

(c) Other diagnoses and/or conditions treated;

(d) All operations and procedures performed and the treatment rendered during current admission, with dates;

(e) Pertinent past history;

(f) Pertinent points in review of systems (including allergies or drug sensitivities);

(g) Pertinent findings of laboratory and radiological data;

(h) Pertinent findings of physical examination, particularly abnormalities;

(i) Brief course in hospital stay to include treatment received and condition on discharge. Condition must be more specific than “improved” and should permit measurable comparison with condition on admission;

(j) Condition of wound, if applicable;

(k) Place of disposition; i.e., home, nursing home, etc;

(l) Discharge instructions to the patient, or responsible other, to include: Information regarding condition or proper home care; medical follow-up. NOTE: If a private physician, state the name if possible; medications on discharge; diet instructions; activity and/or limitations; specific date to return to work.

(8) Discharge Progress Note and/or Discharge Instructions

(a) The physician must complete a discharge progress note and/or instruction sheet for each period of hospitalization. It must contain date and the type of discharge, diagnosis, discharge medications, recommendations relative to diet, exercise, limit of disability, condition on discharge (to include character of surgical wound, if appropriate), place of disposition, recommendations for follow-up, and patient education.

(b) When instructions are given to the patient or designee, the record needs to so indicate. A formal discharge summary does not substitute for a discharge and/or instruction progress note.

(c) 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.

(f) Anesthesia:

(1) Pre-anesthesia Evaluation. The anesthesiologist (or qualified oral surgeon if the patient is a dental patient without medical problems) must complete the pre-anesthesia evaluation. This evaluation must document pertinent information relative to choice of anesthesia (i.e., general, spinal, regional, etc.), surgical procedure anticipated, previous drug history, other anesthetic experiences, and any potential anesthesia problems. The evaluation must include an appropriate physical examination and a review of objective diagnostic data (e.g. laboratory, ECG, X-ray)

(2) Pre-anesthesia Note. The anesthesiologist or anesthetist must document the pre-anesthesia note immediately prior to induction of anesthesia. This note must include a description of the dialogue between the anesthesiologist or anesthetist and the patient (or patient’s representative), and based on: An assessment of the patient’s medication and/or drug history, other anesthetic experiences, potential anesthetic problems, and the type of anesthetic which is to be employed during the planned surgical (or non-operating room) procedure. The pre-anesthesia note must be documented in the progress notes or in the Intra-operative Anesthesia Record. Pre-anesthesia notes must be annotated with the date and time.

(3) Anesthesia Plan. The anesthesia plan must be done by or show concurrence by an LIP with appropriate clinical privileges. Licensed Independent Practitioner (LIP) concurrence can be accomplished at the plan stage or the pre-induction re-evaluation.

(4) Post-anesthesia Care Unit Note (PACU). The PACU documentation must include the patients evaluation on admission and discharge from the post-anesthesia care unit, a time-based record of vital signs and level of consciousness, all drugs administered and their doses, type and amounts of intravenous fluids administered, including blood and blood products, any unusual events including post-anesthesia or post-procedural complications, and post anesthesia visits. The record must document the name of the LIP responsible for the patient's release from the recovery room, or clearly document the discharge criteria used to determine release.

(5) Post-anesthesia Note. The anesthesiologist or anesthetist must document the post-anesthesia note. This note must include the patient’s level of consciousness on entering and leaving the recovery room, vital signs, and when used, the status of infusions, surgical dressings, tubes, catheters, and drains. There must be at least one post-anesthesia visit after leaving the recovery room, and the note needs to describe the presence or absence of anesthesia-related complications. The health record must document the name of the licensed independent practitioner responsible for the patient’s release from the recovery room, or clearly document the discharge criteria used to determine release.

g. Surgeries and Procedures. All aspects of a surgical patient’s care, including ambulatory surgery, pre-operative, operative and post-operative care, must be documented. Surgical interventions, diagnostic procedures, or other invasive procedure must be documented to the degree of specificity needed to support any associated coding data and to provide continuity of care. Informed consent must be obtained in accordance with Medical Center Policy Memorandum 11-11.

(1) Pre-operative and/or Pre-procedural Note. In all cases of elective and/or scheduled major surgery and or diagnostic and therapeutic procedures, and if circumstances permit, in cases of emergency surgery, the staff practitioner will evaluate the patient and write a pre-operative (pre-procedural) note describing the findings of the evaluation, will document diagnosis(es), treatment plan and/or choice of specific procedure to be performed and discussion with the patient and family of risks, benefits, potential complications and alternatives to planned surgery. When a resident completes the note, the staff physician will co-sign if delineated in facility bylaws. Staff practitioners will be responsible for authorizing and/or approving performance of procedures.

(2) Immediate Post-operative Note. A post-operative progress note must be written, or directly entered into the patient’s health record, by the surgeon immediately following surgery and before the patient is transferred to the next level of care. The immediate post-operative note must include: Pre-operative diagnosis, Post-operative diagnosis, Technical procedures used, Surgeons, Findings, Specimens removed, and Complications.

The immediate post-operative note may include other data items.

(3) Operative Report. An operative report must be dictated and completed by the operating surgeon immediately following surgery. NOTE: Immediately is interpreted in some standards of practice as six hours following surgery. Joint Commission defines immediately as "upon completion of the operation or procedure, before the patient is transferred to the next level of care" The body of the report needs to contain indication for the procedure; operative findings; the technical procedure used; specimens removed; post-operative diagnosis; names of the attending surgeon, primary surgeon, and assistants; and indicate the presence and/or involvement of the attending surgeon. See Medical Center Policy Memorandum 11-27.

(4) Recovery Room Note. Post-operative documentation (i.e., Recovery Room Note) must include: Vital signs and level of consciousness; medications and blood and blood components; any unusual events or postoperative complications, including blood transfusion reactions; and the management of such events.

h. Diagnostic and Therapeutic Procedure Reports. Detailed reports of diagnostic and therapeutic procedures not performed in the operating room must be documented in the progress notes by the practitioner performing the procedure, and must contain: The name of procedure; the name of the person performing procedure; details of performance; major findings and conclusions; whether or not tissue was removed; any complications; a signature, a title, and a date.

i. Consultation:

(a) The written or verbal request for a consult may be generated by a LIP, or as otherwise defined by facility By-laws, and documented in CPRS by using the consult request option. The request for consultation must include: A brief description of the patient's condition; the reason for the consultation; other information of value, such as medication which may affect the condition being evaluated; and the electronic signature of the requestor.

(b) The consultant's report of advice, opinion, and any services that were ordered or performed must be documented in CPRS and then the consult is "complete". The authenticated consultation report must contain: an opinion of the consultant's findings for making a diagnosis or for providing treatment advice; an indication the patient was examined; an indication the patient's record was reviewed; the date of the consult; and the consultant's signature.

j. Laboratory and Imaging

(a) Order entry for laboratory tests must be completed in full, clearly identifying the patient, location, requester, test date, special handling, and reason(s) for test.

(b) Requests for tissue examination must contain the preoperative diagnosis and a brief clinical history, including the reason for the examination.

(c) Requests for imaging services must contain a complete reason for the exam with a brief clinical history.

(d) Reports of imaging results must reflect: Patient identity; date performed; date interpreted; type, route, and amount of contrast or radio-pharmaceutical agents used, if applicable; specific preparation of the patient; findings; and name of interpreter.

k. Orders. All orders must contain the date, time the order was written, name of the practitioner placing the order; they must be signed and correspond to the individual’s scope of practice as defined by the medical staff bylaws.

l. Advance Directive. When a patient completes or updates an Advance Directive, a copy must be scanned into the record. The Advance Directive image must include a progress note with an Advance Directive title that appears in CWAD.

(1) Time Standards for Completion of Medical Records:

(a) Current medical records of patients should be completed timely,but within 24 hours of entry. If the medical record is incomplete thirty (30) days after discharge, it will be considered delinquent and will be reported as such to the caregivers' service chief and the Chief of Staff.

(b) Each DischargeHospital Summary, should be completed (reviewed and signed by the final reviewing physician) within ten (10) days following disposition of the inpatient. The SUMMARY SHOULD BE DICTATED PRIOR TO DISCHARGE OF THE PATIENT.

(c) Operative reports should be dictated immediately after surgery and should contain both a description of the findings and a detailed account of techniques used and tissues removed and the name of the primary surgeon and any assistants plus the degree of supervision of the residents.

(d) Any medical records incomplete over two (2) months will be referred to the service chief for review and assistance in completion.

m.

Physicians' Responsibility for Completion of Inpatient Medical Records:

(1) A medical record will be considered incomplete if missing any of the following:

(a) Discharge Summary has not been dictated or entered electronically in Computerized Patient Record System (CPRS).

(b) Summary content does not comply with Joint Commission and/or VA regulations regarding adequate documentation such as lacks final diagnosis; "X" to designate the condition after study to be chiefly responsible for admission of the patient to the hospital; addendum if summary done over a week prior to discharge; summary lacks instructions regarding diet, physical activity, medications and follow-up at discharge.

(c) Summary lacks signature and/or countersignature.

(d) History and physical exam missing or lacks signature and countersignature and date.

(e) Operative report missing or lacks signature and countersignature.

(f) Pre and Postoperative notes lack signature and countersignature.

(g) Doctors' orders lack signature or countersignature as required by policy.

(h) Transfer note incomplete.

(2) Outpatient Medical Record: Each patient discharged from the hospital to an outpatient clinic should have a Problem List completed by the discharging health care provider, in its electronic form.

(3) No medical staff member will be required to sign entries which are not the staff member's own or on an unfamiliar patient. A staff member may summarize a course of treatment based on existing medical record documentation or review a summary for consistency with existing medical record documentation if the original staff member responsible for the patient's care is no longer available. A notation may be made to reflect this is being done from documentation without personal knowledge of the patient.

(4) Declaring a Medical Record Complete: No medical record will be declared complete for purposes of filing until it contains all of the required documentation pertinent to the patient's treatment. Exceptions to this policy are based on the recommendation of the Medical Record Committee to the Clinical Executive Board (CEB). If declared complete the record will contain a notation giving the circumstances under which the record is being filed. Each filed incomplete medical record will have a list of the diagnoses and procedure that were abstracted from the record for Patient Treatment File (PTF) purposes.

n. Emergency and Urgent Care. Urgent care and/or emergency documentation contains the following components: Time and means of arrival; presenting problem(s); i.e., the reason for visit; history and objective data relevant to the presenting problem; assessment of the problem; treatment plan for the problem; primary and secondary diagnoses; i.e., only those dealt with at this encounter; basis for ordering test, consult, or changes in medication; care received prior to arrival; condition at discharge; and discharge instructions.

o. Medical Record Review at the Point of Care: The Joint Commission Medical Review Tool will be used to perform concurrent focused reviews of identified problem areas. Periodically the entire review tool will be used to determine if additional items need to be included in the focused review. Use of computer programs to screen for specific documents will be pursued.

5.

REPORTING REQUIREMENTS: Monthly reports will be submitted to the Medical Record Committee concerning quality and quantity of medical record documentation.

6.

RESPONSIBLE OFFICE: Business Office (136).

7.

REFERENCES: VHA Handbook; PL 93-579, Privacy Act; and Joint Commission Accreditation Manual for Hospitals.

8. RESCISSION: Medical Center Policy Memorandum 136-39, dated April 4, 2014.

Medical Staff Concurrence:

Date: April 6, 2018 /s/ Thomas C. Ferguson, M. D.

Chief of Staff

/s/ David K. Dunning, MPA

Medical Center Director Attachments Attachment A

Policy Memorandum 136-39

Date: April 6, 2018 General Computer Contingency Plan This plan is to be enacted during and immediately following any type of computer system "down time." "Down time" is defined as total shutdown of the medical center's computer system during which time CPRS is totally non-functional. This definition and contingency plan do not apply to situations when the CPRS system slows down (such as in the middle of the night).

1. Medical Care Orders:

a. Hand-written medical care orders during the system "down time" do not have to be re-entered into the computer when it is functional again. During periods of computer "down time," providers are encouraged to hand write only immediately necessary orders. For example, an urgent lab test that needs to be completed should be handwritten; however, an order for a CT scan that is to be scheduled in two days should be entered into CPRS once the system is operational again. Outpatients and clinics should stack/defer those delayed orders until the system is functional, delivering (personally or by fax) only those orders needed at that moment. An inpatient admission or surgical order set should, if possible, be limited to those orders to be completed during the anticipated "down time."

b. In the event that a handwritten order set includes a delayed order (for example, a surgeon writes a post-operative order set that includes a CT for the next day), the unit coordinator will be responsible for entering that delayed order into CPRS once the computer system is operational.

c. Urgent/Emergent verbal/telephone orders will be accepted and documented on a Doctor's Order form.

d. Any service (including Pharmacy) will accept handwritten orders that are received by fax.

2. Notes: Progress notes, Consults, History & Physical (H&P) notes, etc. should be typed into MS Word, then cut, and pasted into the specific area of CPRS once the system is functional again. The user can write progress notes in word and save to My Documents. It is recommended that “My Document” folder on a machine be used in case a situation came that the network was down. User should attempt to remember machine location.

a. If the "down time" exceeds four hours, notes may be dictated using the medical center's dictation system. However, bear in mind that dictated notes are not immediately accessible and that the transcription turn-around time is approximately 48 hours. If you will need to view your note sooner, it is advisable to type it in Microsoft Word and save it in the "My Documents" folder.

b. In the event of a network failure, that disallows the printing of notes for immediate use, and then handwritten notes (Progress notes, Consults, H & Ps, etc.) are acceptable. Please limit handwritten notes to only those that are absolutely required. These notes will be scanned into VistA imaging by the Business Office once the system is functional, so it is advisable to make them as legible as possible.

3. Lab tests: Unit Coordinators should fill out a copy of the three-part backup laboratory test request form. Copies of this form are available on the wards and in the Phlebotomy/Accessioning section of the laboratory. An addressograph must be used to properly identify the patient as to name, social security number, ward, date, time and requested tests.

a. Specimens will be collected in the normal manner. Request forms sent to the laboratory from the wards will be honored during down time. (Please note – the process of analyzing specimens is not hampered by workstation/computer/network failures, only the reporting of results)

b. All patient reports will be initialed by the individual performing the test and by the individual reviewing the test results.

c. All stat and critical values should be phoned as soon as completed.

d. Pathology & Laboratory Medicine Service will document the following:

Called to___________________________(complete name)

Reported by_________________ Date: ____ Time: _____

e. Routine results will be faxed to the floors. The fax document will include a copy of the requisition and a printout of the laboratory results.

4. Consults: Any service will accept emergent or urgent hand-written consult forms. Responses should be typed into MS Word following instructions in #2 above. The "Contingency Note" folder may be used to save the consult note, but it will not be auto-extracted into CPRS. As above, if the consult can wait until the system is operational; it is advisable to delay its input until it can be entered directly into CPRS.

Attachment B

Policy Memorandum 136-39

Date: April 6, 2018 Medical Record Format

1. Inpatient Record

a. Initial Medical History and Physical (H&P) Examination - The progress note title of History and Physical will be used for recording all pertinent items. This must be countersigned by the attending physician.

b. Management Plans - The assessment of the problems and the management plans should be recorded on the H & P and further addressed in the first progress note.

c. Progress Notes - Progress notes shall be entered timely and at sufficient intervals to reflect the physician's ongoing assessment of the patient, as well as whether treatment regimen should continue as previously ordered or whether changes or additions to care plan are indicated. Progress notes will be used for recording pertinent, meaningful observations and information concerning the patient's medical condition and assessments of patient's response to treatment. There will be weekly care coordination notes written on each patient. Each note must be legible, coherent, in correct chronological sequence, and dated and authenticated by its author. There will be statements regarding the effects of various types of therapy (e.g., respiratory therapy). The pre-anesthesia note will be recorded in the progress note by either the anesthesiologist or the surgeon who writes the pre-operative orders. A substantive post-anesthesia note will be recorded by the nurse anesthetist or anesthesiologist in the progress notes or the anesthesia record within 24 to 72 hours after the patient leaves the recovery room. There will be an attending physician's note within 24 hours after admission. The attending physician should indicate approval by signature and date at the end of the H&P.

d. Transfer Note - An inter-service transfer note should provide a concise recapitulation of the hospital course to date, include the indications for transfer and assist the receiving area in providing continuity of patient care. The transfer note must include the diagnoses, treatment plan and active medications at the time of transfer. Transfer notes should reflect appropriate resident supervision.

e. Doctors' Orders - Orders must be recorded in CPRS and electronically signed by the provider. Verbal orders may be accepted by qualified personnel and must be authenticated by the responsible practitioner according to…