36C25618R0078-048.docx

Numbered Memorandum 136-12 Attachment I

Southeast Louisiana Veterans Health Care System New Orleans, LA 70112

Numbered Memorandum Department of Veterans Affairs

136-12 June 30, 2017

CONSOLIDATED HEALTH RECORDS (CHRs)

1. PURPOSE: The purpose of this Numbered Memorandum (NM) is to state policy and procedures concerning development, recording, completion and security of the consolidated health record (CHR), inclusive of the computer based patient record, VISTA Imaging, administrative record, inpatient and outpatient records at the Southeast Louisiana Veterans Health Care System (SLVHCS). A glossary of common terms has been included in Attachment A.

2. POLICY:

a. SLVHCS has an electronic consolidated health record (CHR) in which it maintains a complete and accurate medical record for each individual patient.

b. A CHR will be established and maintained for every patient and will conform to the highest professional standards, meeting and/or exceeding the criteria established by accrediting agencies. Documentation in the medical record is entered in a timely manner which meet (or exceed) VHA and The Joint Commission standards.

c. Electronic storage and capture of patient medical information will be implemented to the extent possible to enhance access to patient data by health care providers, and support personnel with contingency provisions. The electronically stored and/or printed patient information is subject to the same medical and legal requirements as the handwritten information in the CHR.

d. Signature stamps will not be utilized in the record.

e. In all patient care settings, health care providers, within their scope of practice or privileges, will complete an accurate, timely, concise, and relevant account of the patient’s health care. This will be performed using the Veterans Health Information Systems and Technology Architecture (VISTA), computerized patient record system (CPRS), or Text Integration Utility (TIU). Timeframe is the close of business on the day of the appointment.

f. All notes of residents/trainees will be counter-signed by a supervisory practitioner.

g. Use of protected health information will be limited to the minimum amount necessary to accomplish the intended purpose of the use.

3. RESPONSIBILITIES:

a. The Director is responsible for SLVHCS meeting state, local, federal, and The Joint Commission requirements related to the CHR.

b. The Chief of Staff is responsible for the implementation of this policy with all clinical staff and ensuring their compliance with this and all related SLVHCS policies.

c. The Service Chiefs of those staff whose roles and responsibilities are defined within this policy are responsible for ensuring their compliance with the process and procedures outlined.

d. Providers are responsible for functioning within the parameters outlined within their individually approved clinical privileges/scope of practice, for the appropriateness and completeness of all entries into the patient’s CHR.

Staff physicians and dentists as well as all those professionals who supervise students of any profession must follow requirements contained in the SLVHCS Medical Staff ByLaws related to health information management In the case of staff physicians, appropriate supervision of residents and medical students who document in the electronic medical record is a requirement.

e. The Health Information Management Committee (formerly, Medical Records Committee) is responsible for providing oversight of the medical record functions as defined by Quality Management to meet The Joint Commission and VA regulations. It has responsibility for reviewing and recommending approval of SLVHCS policies, rules, and regulations relating to medical records (i.e., medical records completion; both paper and electronic forms; formats; filing sequence of paper documents; approved abbreviations; storage, destruction and availability of medical records). The Committee is also responsible for the ongoing review of CHR for completeness, timeliness, readability (whether handwritten or printed), quality, consistency, clarity, accuracy, and authentication of data/information, and action taken to improve the quality and timeliness of documentation. Recommendations of the Medical Records Committee and results of these reviews are forwarded to the Executive Committee of the Medical Staff for action.

f. Executive Committee of the Medical Staff (ECMS) is responsible for reviewing the findings, conclusions, and recommendations of the monitoring activities and the other recommendations related to other functions of the Health Information Management Committee.

g. Chief, Health Information Management Section (HIMS) is responsible for the administrative management of the CHR. The Chief, HIMS, or designee is responsible for ensuring prompt, accurate transcription of reports. The Chief, HIMS, or designee works closely with the Chief of Staff, Associate Chief of Staff for Education, the Chairperson of the Medical Records Committee, Associate Chief of Staff for Outpatient Clinics, and/or Clinical Service Chiefs or their designees to establish administrative procedures, controls, monitoring, and reporting which foster the prompt preparation, signing, and access/availability of the CHR. Chief, HIMS, along with the Chief of Informatics is also responsible for the review and development of requests for titles and locally developed enhancements, boilerplates/shared templates for proposed use in the CHR for consistency with internal/external standards and for duplication of other medical record content. The Chief, HIMS or designee is responsible for the functionality of administrative procedures, controls, monitoring, and reporting of the electronic medical record in order to support the prompt preparation, signing, coding, and access/availability of the CHR.

h. Chief, Health Administration Service is responsible for establishing administrative procedures, controls, monitoring, and reporting that foster the prompt coding of the CHR.

i. All Authorized individuals who are involved with direct patient care are responsible for documenting patient care activities in the CHR and maintaining appropriate security. Only authorized individuals will make entries into the CHR.

4. PROCEDURES:

a. General: Patient-specific data and information are contained in the consolidated health record, both inpatient and outpatient, to facilitate patient care, treatment, and services; serve as a financial and legal record; aid in research; support decision analysis; and guide professional and hospital performance improvement.

(1) The CHR contains sufficient information to identify the patient, support the diagnosis/condition, justify the care, treatment, and service, document the course and results of care, treatment, service, and promote continuity of care among providers. Standardized formats are used for documenting all care, treatment, and services provided to patients. Each CHR will have, as applicable, the following component parts:

(a) Patient identification (name, sex, address, date of birth, and authorized representative, if any);

(b) Legal status of patients receiving behavioral health care services;

(c) Documentation and findings of assessments;

(d) Conclusions or impressions drawn from medical history and physical examination;

(e) The diagnosis, diagnostic impression, or conditions;

(f) The reason(s) for care, treatment, and services;

(g) The goals of the treatment and treatment plan;

(j) Diagnostic and therapeutic orders;

(k) All diagnostic and therapeutic procedures, tests and results;

(l) Progress notes made by authorized individuals;

(m) All reassessments and plan of care revisions when indicated;

(n) Relevant observations;

(o) The response to care, treatment and services provided;

(p) Consultation reports;

(q) Allergies to foods and medicines;

(r) Every medication ordered or prescribed;

(s) Every dose of medication administered (including the strength, dose, or rate of administration, administration devices used, access site or route, known drug allergies and any adverse (drug reaction);

(t) All relevant diagnoses/conditions established during the course of care, treatment and services;

(u) Records of communication with the patient regarding care, treatment and services, for example, telephone calls or e-mail, if applicable;

(v) Patient-generated information (for example: information entered into the record over the Web or in pre-visit computer systems) if applicable;

(w) Language and communication needs; and

(x) Emergency care, treatment and services provided to the patient before his or her arrival if any

(2) All entries in the record will be dated, and the author identified. The signature in the electronic record will be electronically timed and dated upon completion. At a minimum, the following documents must be authenticated: history and physical examinations, Discharge Summaries, and consultations.

(3) All entries by medical students reflecting medical opinions must be signed by the involved house staff and be authenticated by the staff physician. Opinions requiring medical judgment must be authenticated only by the supervising staff physician.

(4) The staff physician (attending) has multiple responsibilities for the CHR as outlined in the 2017 Medical Staff ByLaws which include countersigning of:

(a) Admission History and physical examination (within 24 hours for acute care admissions)

(b) Progress note indicating his/her concurrence or modification of the residents admitting diagnosis and plan of care if needed;

(c) Do Not Resuscitate or Intubate order and advance directives;

(d) Consultations;

(e) Discharge records (within 48 hours of discharge);

(f) Informed consent (signed by the appropriate staff physician);

(g) Notes related to telephone calls or e-mails with the patient or family members

The staff physician is responsible to assure that the medical record contains information that reflects the patient's care, treatment and services in a thorough and detailed manner and adequate resident supervision to meet supervision requirements. The reason(s) for admission for care, treatment, and services

· The patient’s initial diagnosis, diagnostic impression(s), or condition(s)

· findings of assessments and reassessments

· allergies to food

· allergies to medications

· conclusions or impressions drawn from the patient’s medical history and physical examination

· diagnoses or conditions established during the patient’s course of care, treatment, and services (including complications and hospital-acquired infections)

· consultation reports

· observations relevant to care, treatment, and services

· patient’s response to care, treatment, and services

· emergency care, treatment, and services provided to the patient before his or her arrival

· progress notes

· orders

· medications ordered or prescribed

· medications administered, including the strength, dose, and route

· access site for medication, administration devices used, and rate of administration

· adverse drug reactions

· treatment goals, plan of care, and revisions to the plan of care

· results of diagnostic and therapeutic tests and procedures

· medications dispensed or prescribed on discharge

· discharge diagnosis

· transfer to another level of care during hospitalization (if applicable)

· Discharge plan and discharge planning evaluation and discharge instructions (discharge summary)

· Left against medical advice (if applicable)

(5) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html ) and the Privacy Act of 1974 contain provisions for the amendment or correction of the original hard copy medical record (see Attachment B). The same requirements apply to the CPRS. In order to reflect this requirement in CPRS, (see Attachment B) the Chief, Health Information Management Section (HIMS) or designee will be provided access to the computerized patient record for purpose of amending or correcting the record.

(6) Medical records must be immediately available for patient care. All aspects of the electronic medical record are subject to SLVHCS information security policy, Information Technology (IT) Systems Security Policy.

(7) The CHR of hospitalized patients will be arranged according to the proper procedure set forth in VHA Handbook 1907.1.

(8) Release of Information from the CHR will be the responsibility of the Health Information Management Section (HIMS). CHR information will only be removed from the premises in response to a federal or state court order, statute or subpoena and in accordance with the Release of Information Directive VHA 1605.1.

(9) Consolidated Health Records are reviewed on an ongoing basis at the point of care and based on SLVHCS’ defined indicators that address the presence, timeliness, readability (whether handwritten or printed), quality, consistency, clarity, accuracy completeness, and authentication of data and information contained within the record, as well as appropriate scanning and indexing if document imaging is used.

(10) The Service will identify deficiencies, problems, and enhancements required for the CHR and will request assistance from Informatics and the Clinical Applications Coordinator (CACs) in the development of solutions for improvements or modifications to locally developed templates, boilerplates and CPRS. All proposed enhancements, modifications, or changes will be approved by the Service Chief and forwarded electronically by Informatics and the CACs for recommendation to the Medical Records Committee, as outlined in Attachments (C, D, E, F, G), for action and recommendation to the Executive Committee of the Medical Staff (ECMS).

(11) Only approved abbreviations, acronyms, and symbols will be used in the CHR. Each abbreviation, acronym and symbol will only have one meaning (see local policy of approved abbreviations). Local policy contains a list of dangerous abbreviations, acronyms, or symbols not to be used.

(12) Retention policies and guidelines are found in VHA Records Control Schedule RCS 10-1. The hard copy Consolidated Health Records are maintained in the File Room for three years after the last episode of care and are then forwarded to the Federal Records Center for storage. CPRS is the electronic patient record stored in VISTA indefinitely.

(13) Progress notes will be recorded electronically in CPRS. Amendments and Corrections to progress notes will be in accordance with Attachment B. The hospital defines, consistent with law and regulation, which entries made by non-independent practitioners requires countersigning. Only electronic progress notes or scanned documents will be filed in the CHR; paper copies will not be permitted. Progress notes will be electronically available in VISTA. Only authorized employees performing official VHA duties will print, whole or in part, the electronic medical record.

(14) The electronic function of copy and paste is a powerful tool; however, this functionality must be used with caution and according to policy as delineated in Attachment H.

(15) The CHR is not considered complete until the required contents, (i.e., manual or electronically signed orders, or progress notes) are assembled and authenticated, and when all final diagnoses and any complications are recorded. No non-electronic components of the CHR shall be filed until it is complete, except by order of the Chief of Staff in accordance with VHA Handbook, 1907.1.

(16) The process of maintaining an accurate electronic medical record requires that certain procedures for recording information and interaction with the record be established and adhered to by persons allowed to use the software. Detailed instructions on the proper use of the VISTA/CPRS software can be found on the Intranet on SLVHCS Policies page. As processes and procedures change, the Intranet will be updated to reflect the most current changes. The website may be accessed from the CPRS TOOLS menu, then selecting the item from the CPRS Help Page.

(17) Personnel will be classified into functional categories based on the duties and responsibilities of the individual. In accordance with guidelines set forth in VHA Handbook 1605.2, access to the CHR will be granted based on categories of protected health information needed and the conditions appropriate to such access.

b. General: Outpatient Records

(1) The CHR of a patient receiving care will note the times and means of arrival; whether the patient left against medical advice; the conclusions at termination of treatment, including final disposition; condition at discharge; instructions for follow-up care, treatment and services; any patient/family education provided; and notation that a copy of the record is available to the practitioner or medical organization providing follow-up care, treatment, and services.

(2) When a patient is first admitted to VA care on an ambulatory basis, relevant history of illness or injury and physical findings including vital signs shall be recorded.

(3) Each new patient must be seen by or discussed with the attending/staff practitioner and documented at time of first visit as required in the SLVHCS ByLaws and resident supervision requirements.

(4) Return patients shall be seen by the attending/staff practitioner with such frequency to ensure that the course of treatment is appropriate and effective, commensurate with patient’s condition, significant change in condition, treatment plan or care setting. Such medical staff supervision must be documented via a progress note by the attending practitioner or via the resident’s progress note with the attending physician’s name and summary of the discussion included as required in the SLVHCS ByLaws and resident supervision requirements.

(5) For patients receiving continuing ambulatory care services, the CHR contains a summary list of all significant diagnoses, procedures, drug allergies, and medications. A list of all relevant clinical problems, including known significant medical diagnoses and conditions, known significant operative and invasive procedures, known adverse and allergic drug reactions, and known long-term medications, including current prescriptions, over the counter drugs and herbal preparations will be initiated by the third outpatient visit and updated as necessary upon subsequent encounters for ambulatory care. Documentation is through CPRS Problem Tab (See Attachment I), the Surgery Package and CPRS Surgery Tab, the Adverse Reaction Tracking Package, or the electronic encounter form.

c. Contingency: In the event of a disaster, patient CHR will be recreated based on available electronic and/or hard copy records. Electronic patient records will be recreated from stored offsite DLT4 VISTA backup tapes. Hard copy records created will be scanned into the CHR following the aftermath of the disaster. If the CHR is not available, Services must refer to their local contingency plans. Once CPRS is available responsible clinics will input data into the patient’s file.

5. RESCISSIONS: Numbered Memorandum, Consolidated Health Records (CHRs), dated December 13, 2010.

6. REFERENCES: Comprehensive Accreditation Manual for Hospitals, Joint Commission; 2017 Bylaws, Rules, and Regulations of the Medical Staff; VHA Handbook 1400.01 dated December 19, 2012; VHA Handbook 1907.1, Health Information Management and Health Records, May 19, 2015; VHA Directive 1605.01, Privacy and Release of Information. August 31, 2016; and VHA Directive 5021, Employee Management Relations, May 31, 2017; VHA Directive 6500, Information Security Program, September, 18, 2007.

7. FOLLOW-UP RESPONSIBILITY: Chief, Health Information Management Service

8. EXPIRATION: June 30, 2020

(Signed) Fernando O. Rivera Director/CEO, Southeast Louisiana Veterans HCS

Attachments: A through I

SUMMATION OF POLICY & PROCEDURE CHANGES: None

ATTACHMENT D41- HOUMA

GLOSSARY OF TERMS

Alert Team - An electronic grouping of user names that will receive alerts for a designated group of patients or for a specific type of notification. Teams are also used to control access to certain software functions as with Consult Tracking.

Boilerplate - A pre-defined electronic document template that can be modified to meet specific needs which is attached to a specific note title/consult and appears whenever that title/consult is used.

Business Rule - A logical rule based on user classifications that determine what software functions are available to that user. At present, TIU business rules determine various authorities concerning Progress Notes and Discharge Summaries such as requirements for co-signature, viewing of documents, editing of documents etc.

Chart Flag - In CPRS there is a display in the upper right corner of the electronic chart that may contain any combination of four letters CWAD. These function in the same manner as flags on the paper chart. They serve to call attention to the person that opens the record to important information about the patient. (See also “Patient Record Flag”)

Clinical Reminder - A Clinical Reminder is a logic-based query that offers a means to alert providers to specific patient needs based on a variety of patient attributes that are recorded in the electronic record. The reminder is divided into two logical evaluations. The first is referred to as Cohort Logic and determines if the patient fits the criteria outlined to have the reminder displayed. The second is Resolution Logic, which establishes the criteria by which the reminder is satisfied. Reminders may be set to be satisfied for a specified period of time and then become active again. Each reminder can be set to be evaluated when a patient’s record is opened under a variety of conditions such as specific clinics, individual users, or for all users of CPRS. An example would be a reminder to check blood pressure on a patient every six months. This reminder would trigger if a patient was seen and did not have a blood pressure on record within the previous six-month period. Recording a blood pressure would satisfy the reminder for six months and it would not be displayed. Reminders may also be used to provide lists of patients that fit specifically defined criteria by printing Reminders Due Reports after establishing Cohort Logic.

Clinical Warning - A note that contains information to call to one’s attention or give notice to beforehand usually identified with the word FLAG beginning the note title. Writing a Clinical Warning title produces an alert to the users in the Postings Box of CPRS at the top right corner of the chart.

Numbered Memorandum 136-12 Attachment A Computerized Patient Record System (CPRS) - CPRS is a computer application that is part of the Veterans Health Information System Technology Architecture (VISTA) which provides Graphical User Interface (GUI) access to the VISTA patient database. The CPRS user interface is patterned after the index tabs of a paper chart and functions in an integrated fashion with other components of the VISTA system such as VISTA Imaging. Together with other automated system components it provides easy retrieval of complete, accurate, and timely medical information. These software programs are the foundation for the Consolidated Health Record

Consolidated Health Record (CHR) - The scope of the VA medical program expands the traditional concept of a patient record by using a CHR. The CHR consists of both the hard copy and the computer-based patient record. The CHR can be called the medical record, the patient record, the health record, and the computer-based patient record. The CHR consists of the following record types: Medical Record, Administrative Record, Outpatient Record and the Computer-Based Patient Record.

Consult Management (Outpatient Consults) - A staff group that screens all outpatient consults for specialty care. Consults containing information requested in pre-defined criteria are forwarded for approval to the specialty Service’s designee. Once approved, the Consult Management staff makes appointments. They are also involved with processes to insure appropriate handling of outpatient consults by the Services.

Consult Service - This term is not to be confused with the hospital administrative term Service. It is used to indicate a point of tracking within the Consult/Request Tracking package, which provides services to the clinical providers. In some instances, it may correspond with an administrative service category. A separate Consult Service is set up whenever it is desirable to allow independent delivery of alerts, printing of consults, and tracking of incomplete results to different persons or locations.

Consults/Request Tracking Package - This is a VISTA software product which is integrated with the CPRS application and facilitates electronic ordering, tracking, and completion of both consults and procedures.

Crisis Note - A note title that contains a progress note which documents an unstable or crucial time or state of affairs in which a decisive change is impending; especially one with the distinct possibility of a highly undesirable outcome. Writing a Crisis title produces an alert to the users in the Postings Box of CPRS at the top right corner of the chart.

CWAD (Crisis, Warning, Allergy, Directives) - An acronym that stands for Crisis Warning Allergy Directive. One or more of these letters appears in the upper right corner of the electronic patient chart to alert the provider that information of the type indicated has been entered on the patient. Display of these letters is dependent on the entry of special Progress Notes and information in the Adverse Reaction Tracking (Allergy) package.

Dialog Template - Predefined note text accessed through the Templates Folder, which appears in CPRS on the notes tab. This differs from a standard template in that the user can interact with the template form using check boxes, buttons, etc. to activate sections of the form. Special data fields are available to control user input. These templates may also contain Patient Data Objects.

Document Class - A grouping used by the TIU package to link multiple note titles together so that they share similar attributes and business rules.

Electronic Patient Record - A term used to refer collectively to all the information in a patient’s health record, which is stored electronically including information entered electronically, image data, and scanned documents.

Locally Configurable Components - VISTA software products are designed to allow individual VA Medical centers to configure the software according to their facilities unique needs. This term refers to those aspects of the software which are so designed as opposed to attributes of the software which have predetermined functionality and can only be configured by altering nationally distributed program code. Alterations of this type are referred to as “local modifications” and are discouraged and not supported. Independent software code, which is referred to as CLASS III software, is not discouraged and is also not supported nationally.

Object (Patient Data Object) - Special markup text that causes the template to insert information from VISTA database into the text of the Progress Note such as lab values or patient demographical data. Text containing data from patient objects should not be copied and pasted between patient records as the information is patient specific and is not automatically updated when copied.

Order Dialog - A dialog box that opens when placing an order which prompts the user for all of the various information elements required to place an order for the particular orderable item selected.

Order Menu - A box which contains buttons which when clicked can open order dialog boxes, immediately place pre-defined orders, begin executing order sets, or open additional order menus.

Order Set - A group of linked Quick Orders, Menus, or other Order Sets, which execute in sequence when the order set is started. This facilitates automated ordering sequences for a variety of purposes such as pre-op or post-op orders, clinical pathways, or groups of tests ordered consistently for certain conditions.

Patient Record Flags - These are Pop-Up Display flags that appear both in CPRS and VISTA Character Based applications when a patient name is selected. This application was created specifically to address Disruptive Behavior flags to enhance employee safety. Patient Behavior flags are distributed to all sites that register the patient. A Progress Note is automatically linked to the PRF for details as to the reason for the flag. The PRF package also accommodates development of Local flags for other purposes however the number of these in use should be limited so as not to distract from the importance of this warning.

Progress Note Title - A pre-defined grouping for storing Progress Notes that allows for easy retrieval of specific patient information and also provides TIU software with a point of control which may have specific attributes concerning software behavior. For example, the title H&P Note may be made viewable before Co-Signature while all other progress notes are not.

Quick Order - Normally when a provider places and orders there are many information fields that must be completed prior to accepting the order. Quick order may be created that have pre-defined values entered for all or some of these fields that can greatly expedite the process of electronic order entry.

Reminder Dialog - Clinical Reminder Dialogs allow a user to enter information that resolves a Clinical Reminder from a single dialog display box in the electronic chart. The dialog can record visit elements such as Health Factors, Immunizations, Education Topics etc. and also place orders automatically. In addition, text is automatically entered in the progress note indicating what was recorded. Reminder Dialogs can also be used independent of Clinical Reminders to provide a means to automate recording of patient information, entering orders, and writing text in progress notes in a single operation.

Service/Section Chief - Either Service Chiefs or other supervisor as designed by the Service Chief, such as a section or unit chief.

Template - Predefined note text that is associated with an icon in the Template Folder, which appears in CPRS on the note tab. The user can add the text to a progress note. Pre-defined note text that may or may not be associated with a note title. Clicking the Templates Drawer button on the Progress Notes tab of CPRS allows the user to access these templates. The two main folders are labeled My Templates (those created by the user) and Shared Templates (those created by CPRS support staff). Shared Templates are standardized forms approved by Medial Center management and cannot be altered by the user. (See attachment C). The template text can be inserted into existing text or as stand-alone text on a blank note.

TIU (Text Integration Utilities) - The VISTA software package that maintains the data warehouse of all text documents associated with the patient record. It provides for electronic signature authentication of records and a variety of other control functions associated with written text.

VISTA (Veterans Health Information Systems Technology Architecture) - The acronym used to identify all of the technologies that comprise the unique electronic health care record maintained by and shared among all Veterans Administration medical facilities. VISTA is the new name for the software previously referred to as the Decentralized Hospital Computer Program (DHCP), which has been expanded to include a variety of new technologies. VISTA software is in the public domain and is used by hospitals throughout the world.

Numbered Memorandum 136-12

ELECTRONIC DOCUMENT AMENDMENT/CORRECTION

1. There will be times when electronic entries will require correction or amendment. The Privacy Act of 1974 provides provisions for amendment and correction of the original hard copy medical record. The same requirements apply to the CPRS.

2. Information contained in the CHR must be accurate. If an entry or a portion of an entry in the paper record is found to be incorrect, a single line will be drawn through the incorrect information without obliterating the original entry, with initials and date of the correction. The correct information will be added, if appropriate; a note will be made to indicate why the correction is necessary (i.e., the entry was made in the wrong person's record, there was a copying error or laboratory error, etc.); and the notation will be signed and dated by the person who documented the inappropriate or erroneous entry. If a supplemental or corrective statement is needed, it should be entered in the record chronologically by date of the entry. The supplemental/correction should indicate the entry to which it has reference.

3. The System Manager of patient medical records, identified as the Chief, Health Information Management Section (HIMS) or designee, is provided access to the electronic record for purposes of amendment or correction of the record.

4. When an entry has been found to be erroneous in the CPRS, provisions have been made available to amend the erroneous record. Specifically, the original entry will be marked to indicate that it has been amended, and the amendment will be displayed or printed with the original entry whenever that entry is retrieved. The action will be made possible by the use of a special utility in the TIU software package located under the Medical Information Section (MIS) Managers Menu.

5. It is recognized that in rare instances, it may be necessary to correct an erroneous entry even if the patient is unaware of the error, or even if the patient does not originate such action. In such cases, the note should be brought to the attention of the Health Information Management Service (HIMS), Privacy Officer, or designee. Completed notes or addenda, either entered on the wrong patient or containing erroneous information, must be retracted. This will prevent users other than the HIMS Chief, Privacy Officer, or designees from viewing or printing the contents of the document. When an erroneous note is discovered, the user should write an addendum to that note indicating that either the note, or a specified (date/time) addendum on the note, has either been written on the wrong patient or contains erroneous data. If the contents of the note does not contain patient data objects (labs, active meds, etc) the note can be copied to the correct patient’s record, however, use caution when doing this. Once the note has been retracted the contents cannot be viewed for copying. After signing the addendum, call the HIMS Chief, Privacy Officer, or their designee and request that the note be retracted which then allows viewing of these notes only by the designated HIMS personnel.

Attachment B

REQUESTS FOR ENHANCEMENTS AND MODIFICATIONS TO LOCALLY CONFIGURABLE COMPONENTS OF PROGRESS NOTE AND DISCHARGE SUMMARY SOFTWARE

1. Progress Note titles, boilerplates, and shared templates

a. For purposes of this procedure components refers to progress Note titles, boilerplates and shared templates. See Attachment A for definitions of other terms used.

b. Requests for enhancements or modification to components will be submitted to the VHANOL Document Review Team mail group in Microsoft Outlook. Requests for boilerplates and templates should include a prototype layout for the template. Communication concerning implementation of requests will be handled through electronic mail. If the need arises, Clinical Information Management (CIM) staff and/or the Document Review Team (DRT) may request meetings with appropriate staff from one or more Services to discuss process issues relating to the request. A link to the Process for Requesting Development/Editing of Documents can be accessed from the CPRS Help page and is outlined below.

(1) General: A Document Review Team (DRT) has been formed and the following process has been adopted in order to create an effective and efficient method for the development and implementation of new documents or significant changes to old documents. The DRT is a subcommittee of the Medical Record Committee (MRC) and consists of:

(a) Chair of the MRC;

(b) Chief of HIMS or designee;

(c) Clinical Information Management CIO or designee;

(d) Quality Management (QM);

(e) Compliance Officer; and

(f) CPRS Development Team

1 Priority documents development will be prioritized as follows:

a Health Care System Wide for Patient Safety;

b Health Care System Wide for Joint Commission or other mandated program implementation;

c Services for Joint Commission or other mandated program implementation;

Attachment C d MRC/CPRS Team recommended record improvements;

e Service for record improvement;

f Area for record improvement; and g Individual or less than 3 users requests

(2) The person requesting the document will electronically submit the request via MS Outlook (with the concurrence of the requester’s Service Chief) to the Document Review Team at VHANOL Document Review Team

(3) Requests will include:

(a) the need/rationale for the document;

(b) what the new document will replace (if applicable);

(c) the intended users, including who will be the document signer/co-signer;

(d) a realistic estimate of how soon the document is needed; and

(e) an attached document description in MS Word. The document description will include:

1 The proposed title a A draft of the document (please refer to Numbered Memorandum DO NOT USE Abbreviations to ensure that any abbreviations requested for your template is not on the “List of Dangerous Abbreviations, Acronyms, or Symbols Not to Be Used”;

b The general format desired, e.g. radio buttons, pull down menus, check off boxes, comment boxes (for free text), etc.;

c Whether or not the choices should remain displayed in the final note versus just the selected items remaining in the final note); and d Any other additional information needed for the final document, e.g. template, boilerplate, etc.

(4) If approved by the DRT, the CPRS development group will work with the requester to develop the document

(5) After DRT review and approval of the developed document, it will be electronically forwarded to the Medical Record Committee members. The MRC members will receive the completed document as well as a link to the template in the CPRS “Template Testing” folder.

(6). If there are no concerns expressed during the response period, the document will be forwarded, after the following MRC meeting, to the Executive Committee of the Medical Staff with a recommendation for approval. If MRC members express any concerns about the new document, it will be discussed at the following MRC meeting with the requester or a member of the requester’s Service.

c. Service Chiefs are required to approve these requests prior to action by CIM staff. If requests submitted do not already have approval within the message trail, they will be forwarded to the Service Chief by CIM staff (see Attachment D – Template Approval Process).

d. These requests also require Medical Records Committee approval. The VHANOL CIM CIM representative on the committee will present the requests at the next meeting unless there is an urgent need for the changes. Urgent requests will be addressed as specified in Medical Records Committee policy. If requests from one Service have an impact on another, it is expected that these issues will be resolved in the Medical Records Committee.

e. The Executive Committee of the Medical Staff must approve all progress note titles, boilerplates, and shared templates as recommendations from the Medical Records Committee.

2. Business Rule Modifications

a. Requests to modify TIU Business Rules usually arise as a result of some specific need concerning the function of Progress Note, Discharge Summary software, Bylaws, Rules and Regulations of the Medical Staff and VHA Handbook. As such, it is usually CIM staff that determines what business rule(s) is needed to accomplish the indicated function.

b. Non-Mandated requests also require Medical Records Committee approval. The CIM staff representative on the committee will present the requests at the next meeting. If requests from one Service may have an impact on another, it is expected that these issues will be resolved in the Medical Records Committee and referred to Executive Committee of the Medical Staff.

c. In some instances, it may be necessary to make immediate changes to a Business Rule because of a problem that impacts patient care. If this arises, and CIM staff determines that this can be accomplished without overall negative impact, a rule may be temporarily modified and the change will be communicated to Medical Records Committee members for comment.

3. CWAD Titles (Chart Flag Requests)

a. Certain progress note titles trigger flags on the CPRS patient chart in the CWAD display. Progress notes entered under titles in the Document Class of Crisis Note, Clinical Warning, and Advance Directive (CWAD) will trigger a CWAD flag.

b. There is one Crisis Note title that should be used for appropriate situations related to patient care. The author of a Crisis Note is responsible for changing the title of this note to Inactive Crisis Note to remove the information from the CWAD display when appropriate. When the author of a Crisis Note is no longer an active member of the Service/Section a current member of the Service/Section will enter and sign and addenda on the note stating the reason the note is to be inactivated and notify the Health Information Management Service (HIMS) Privacy officer or designee to inactivate the Crisis Note (Attachment B).

c. A number of titles have been created in the Document Class Clinical Warning for use as “flags” in the CPRS electronic patient chart CWAD display. Requests for additional titles within this document class will be submitted to the VHANOL Document Review Team mail group in Microsoft Outlook as describe above in 1b(a).

d. Service Chiefs are required to approve these requests prior to action by CIM staff. If requests submitted do not already have approval within the message trail, they will be forwarded to the Service Chief by CIM staff.

e. Flag titles may represent either permanent or temporary attributes of the patient. Before a flag title can be approved, there must be a specific plan for maintenance of the information. Flag titles may be re-titled to their inactive equivalent to remove the information from the CWAD display on the chart.

f. These requests require Medical Records Committee approval. The CIM representative on the committee will present the request at the next meeting. Because of the broad ranging impact of patient record flags, the committee may decide to refer these requests to the ECMS for discussion.

4. Patient Record Flag System (National Package)

a. This will be utilized for Disruptive, Threatening or Violent Behavior patients, category I National Behavior information about high risk patients which will automatically be shared across all known treatment facilities for that patient (see Numbered Memorandum Prevention and Management of Disruptive Behavior.

b. This flag will be entered, changed, or inactivated only by a small group of specially trained clinicians operating under the authority of the Chief of Staff. This flag includes such incidents as:

(1) Physical violence against patients or employees.

(4) Suicidal or Para-suicidal behavior on station.

(5) Repeated nuisance, disruptive, or larcenous behavior.

(6) Offensive racial, sexual, or other comments or behavior of a threatening or harassing nature.

c. Category II flag is a locally developed flag that will be used only when a need to have a non-National Behavior flag display upon opening the patient chart is required. The use of category II flags will be limited to only necessary flags which have been approved by ECMS prior to development by the CIM, to prevent excessive flag displays when accessing CPRS. Request for additions of category II flags will be submitted using the Process for Requesting Development/Editing of Documents as outlined in 1b(a).

TEMPLATE APPROVAL PROCESS

Attachment D

The following is a description of the Template Approval Process Flowchart

· First, Template/Title new development/edit request is initiated and approved by Service Chief (s).

· Next, the request is sent to VHANOL Document Review Team (DRT).

· The first question to ask: Are the changes of modifications requested by DRT?

· If the answer is yes that the changes or modifications are requested by DRT,

· The request is returned to the originator for review and changes

· The request is then sent again to the VHANOL Document Review Team (DRT) and the process begins again.

· If the answer is no that the changes or modification are requested by DRT

· The CPRS Team develops/edits the requested document.

· The request is then sent to the Medical Records Committee.

· The next question to ask: Is the request approved?

· If the answer is yes that the request is approved

· The request is sent to ECMS.

· The next question to ask: Is the request approved?

· If the answer is yes that the request is approved

· The minutes of the ECMS are approved with the Director’s Signature

· The template is then placed into production

· If the answer is no that the request is approved

· The question to ask: Are the modifications requested?

· If the answer is yes that the modification is requested

· The request is returned to the originator for review and changes

· The request is sent again to the VHANOL Document Review Team (DRT) and the process begins again.

· If the answer is no that the modifications are requested

· The request is rejected and the requestor is notified.

· If the answer is no that the request is approved, the question to ask: Are the modifications requested?

· If the answer is yes that the modification is requested

· The request is returned to the originator for review and changes

· The request is sent again to the VHANOL Document Review Team (DRT) and the process begins again.

· If the answer is no that the modifications are requested

· The request is rejected and the requestor is notified.

REQUESTS FOR ENHANCEMENTS AND MODIFICATIONS TO LOCALLY CONFIGURABLE COMPONENTS OF PROVIDER ORDER ENTRY CPRS SOFTWARE

1. Quick Orders

a. Users of CPRS have the ability to create personal quick orders for laboratory and medications only to expedite the order entry process. In some instances, it may be advantageous to create quick orders that can be shared by all users in a particular patient care area. This is typically accomplished by adding quick order items or sub-menus containing quick order items to the menu of a specific ward or clinic location.

b. Any CPRS user may submit requests for the addition of quick orders to menus. Requests will be submitted to VHANOL Document Review Team using Microsoft Outlook following approval by the Section Supervisor and/or Service Chief. Communication concerning implementation of requests will be handled through electronic mail if possible. If the need arises, Clinical Information Management (CIM) staff may request meetings with appropriate staff from one or more Services to discuss process issues relating to the request.

c. Requests for the addition of quick orders to menus usually have no impact other than the restructuring of menu designs to accommodate the additional buttons. However, because multiple individuals use menus, and items placed on those menus suggest an approval for the regular ordering of that item, these requests should be reviewed by the Section Supervisor and/or Service Chief. Section Supervisor and/or Service Chief are required to approve these requests prior to action by CIM staff. If requests submitted do not already have approval within the message trail, they will be returned for approval to the appropriate Section Supervisor/Service Chief.

2. Order Sets

a. Order sets contain groups of Quick Orders that are applicable to a specific clinical purpose. These may consist of small groupings of orders that are approved for a specific circumstance, or an extensive combination of automated sets and menus that provide a pathway for placing orders associated with a particular patient condition or event. These are similar to “overprinted” forms used in the paper record.

b. Requests for order sets should involve a collaborative effort and consensus among providers in a given discipline. The completed orders must be submitted to VHANOL Document Review Team electronically using Microsoft Outlook electronic mail with the approval of the Section Supervisor and/or Service Chief. The items in an order set must indicate all necessary information required by CPRS to place the order. When information such as dosages or schedules is to be variable indicate this with a blank line. (i.e. Schedule: ___). Communication concerning implementation of requests will be handled through electronic mail if possible. If the need arises, CIM staff may request meetings with appropriate staff from one or more Services to discuss process issues relating to the request.

Attachment E

c. If requests from one Service have an impact on another, it is expected that these issues will be resolved in the Medical Records Committee. The CIM representative on the committee will present the requests at the next meeting.

d. In some instances, it may be necessary to make changes to menu structures involving the arrangement of items because of overall menu design problems. If this arises, and CIM staff determines that this can be accomplished without overall negative impact, a menu may be modified and the change will be communicated to the Section Supervisor for comment.

3. Delayed Orders

a. Are used when a patient is scheduled in advance to be admitted for treatment/surgery, transfer to…