D.19 DOCUMENT SCANNING POLICY.pdf

D.19 DOCUMENT SCANNING POLICY

36C25922R0102

DEPARTMENT OF VETERAN’S AFFAIRS HEALTH CARE SYSTEM

OKLAHOMA CITY, OKLAHOMA

Center Memorandum 136-44 March 28, 2018

DOCUMENT SCANNING POLICY

1. SUMMARY: Center Memorandum 136-67 is a revised center memorandum.

2. PURPOSE: To state the policy and procedure for scanning documents that cannot be entered directly into the Computerized Patient Record System (CPRS) and VistA.

3. POLICY: The Oklahoma City VA Health Care System is committed to creating an environment that promotes the use of the electronic medical record by defining policies, objectives and responsibilities for scanning of documents related to patient care.

a. Only documents, which cannot be entered directly into CPRS or VistA, will be scanned. Scanned documents will be made available to all clinical and support staff who currently have access to CPRS.

b. Documents, which cannot be created within CPRS, will be scanned and indexed using VistA Imaging or DSS Doc manager. These documents include, but are not limited to, Advance Directives, medical record information from non-VA facilities, including Discharge Summaries, Operative Reports and/or Procedure Reports, medical records from non-VA facilities needed for Non-VA Care programs, and flow sheets, as approved by the Medical Records Committee (MRC). The Health Care System will utilize a number of different scanning locations and scanning staff. Chief of Health Information Management Service (HIMS) will specify the location where each type of document will be scanned and will maintain a current list of document types being scanned and their scanning location (Attachment A).

c. Outside medical records (i.e. medical record information from non-VA facilities and providers) supplied by a veteran or requested by a VA clinical provider will be reviewed by the responsible clinician receiving the records. If the clinician decides that any individual outside document should be readily available for ongoing patient care, the provider will identify it by completing the form number 635-136D-001:02 “Scanning Outside Medical Records”. (Attachment B). The documents and the form will then be forwarded to the Medical Records Scanning Unit (136D). The completed form will be scanned as the last page of the document. Documents not identified by a clinician to be included in the medical record will be destroyed according to facility destruction protocols. In accordance with VHA Handbook 1907.01, Health Information Management and Health Records, 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.

4. GUIDELINE FOR SCANNUNG ADVANCED DIRECTIVES, POWER OF ATTORNEY,

MEDICAL ADMINISTRATION FORMS, DOCUMENTS GENERATED DURING ANY

http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469

COMPUTER DOWN TIME.

Center Memorandum 136-67, March 28, 2018

a. Advance Directives

(1) Social Work Service will create an Advance Directive progress note which is displayed in Postings in CPRS.

(2) Advance Directive documentation should be linked to the Advance Directive note.

(3) Documents are to be scanned and reviewed for quality by the person scanning. During the first quality check, the image will be checked for the overall quality and visibility of the document. The person scanning will be responsible for reviewing each image, ensuring that the demographic information is correct on every page, ensuring the image is positioned as correctly as possible, and ensuring that all pages of documents have been captured in VistA Imaging, which may include blank pages when applicable. The second quality check of the scanned document must be verified by logging into VistA Imaging Display. The responsible person scanning the document will perform both processes.

(4) When an Advance Directive is no longer active, the person scanning will ensure an addendum has been entered by the responsible practitioner stating the patient is rescinding his/her Advance Directive.

(5) The title of the note will be changed in CPRS to “Rescinded Advance Directive”.

The image originally attached will still be visible but will be watermarked with the word rescinded. Note should remain intact in case any action was taken based on the Advance Directive between the dates the document was scanned and rescinded.

b. Administration Forms: Administration forms are scanned in by Eligibility Department, pre-set scanning tabs are set to ensure all staff is scanning uniformly.

c. Computer Downtime: In the event of computer downtime inpatient records will be scanned by Ward Administrations staff and outpatient records will be scanned by HIMS staff.

5. Guideline for scanning Purchased Care/Fee Document see Attachment C

a. To provide guidance for accepting and managing health information received from Non-VA Purchased Care providers, regardless of the format (paper, scanned, or electronic media). This document provides guidance on capturing documents in an Image Capture Program from an external provider; it does not identify what documents are required from the external provider.

b. Non-VA Purchased Care providers that fall under local healthcare contracts should follow the requirements outlined in the individual facility contract. If no requirements exist, then the guidance outlined in this document must be followed. All administrative and clinical information pertaining to non-VA purchased care must be maintained in the patient’s consolidated health record to support decisions to approve or deny claims.

Veterans have the right of appeal of any decision with which they may disagree. The Veteran or vendor can appeal a VA decision up to a year after denial, and if appealed the

Center Memorandum 136-67, March 28, 2018 appeal may take many years to resolve. Therefore, it is imperative that all correspondence, VA authorizations, CMS billing forms including clerk processing notations, VA DRG pricer report for inpatient care, Repricing Agent documents, VA record of refunds or collection actions, Reports of Contact, etc. be retained as part of the administrative record. The clinical documentation supports decisions on approved or denied claims, point of stability, if a facility was on divert status, refusal of transfer by the patient or family member, etc.

c. It should be noted that documentation is not a requirement for payment of authorized claims. Payment of authorized claims must not be held pending the receipt of documentation from the external provider.

d. Guidance: In accordance with VHA Handbook 1907.01, Health Information Management and Health Records, in regards to Non-VA Purchased Care health records, copies of reports submitted by physicians and other reports (laboratory, X-ray, etc.) must be filed in the health record or captured into Image Capture within the locally established time frame. NOTE: Electronic or scanned entry is preferred over paper records. VISN 16 Purchased Care Scanning is an operational procedure that is to be completed by the facility purchased care (fee) staff. The Purchased Care Documents are to be linked to the appropriate CPRS Consult. The consult will remain open until the episode of care is resolved. Note: if a single consult evaluating an episode of care is resolved or the initial evaluation is scanned, subsequent evaluations can be linked to a closed consult.

e. All documents must be authenticated by the originating Non-VA provider of care prior to inclusion into the VHA health record. Authentication may include a written signature, written initials, or electronic signatures. If unsigned documents are received, attempts should be made to work with the Non-VA care provider to obtain authenticated documents. VHA Handbook 1907.01, Health Information Management and Health Records, paragraph 6.j.(8) also states that 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. If signed documents are unable to be obtained, a summary progress note must be entered in lieu of scanning and the guidance pertaining to a summary progress note should be followed in lieu of scanning the unsigned documentation. When dialysis documentation is received, please refer to the Non-VA Care – Dialysis Standardized Titles Fact Sheet for guidance. If a deviation from this guidance is justified, the process should be detailed, defined and approved by the Medical Records Committee or equivalent committee.

NonVA Care - Dialysis

f. Only those documents that cannot be created in, or interfaced with, CPRS will be scanned and development of scanning policies is a shared responsibility among HIM and http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469 other appropriate services. CPRS documents from VA medical facilities must not be printed and scanned into VistA Imaging as the documents can be viewed in VistA Web and Remote Data View. Scanned images, digital x-rays, and other digital images from other

Center Memorandum 136-67, March 28, 2018 facilities can be viewed in Remote Image View. It is strongly recommended that staff be adequately trained on the proper selection of titles and procedures to scan documents into Image Capture. NOTE: VISN 16 developed Purchased Care Indexing (note) Titles which are to be used when linking scanned documents to the consults. For regular purchased care consults the note title is “Fee xxx (cardiology, dermatology, etc.). For inpatient care the note title is “Non- VA Hospitalization.” For Dialysis use the note titles in the embedded document entitled Non-VA Care-Dialysis, listed in the previous paragraph.

6. RESPONSIBILITIES:

a. The Chief of HIMS ensures that all requests to add document types to be scanned are approved by Medical Records Committee.

b. The Chief of HIMS or designee(s), is/are responsible for monitoring image quality and ensuring that all staff members with scanning responsibilities are properly trained.

c. The Medical Records Committee Chairperson has been designated by the Chief of Staff to ensure enforcement of these policies and provide the Chief of HIMS or their designee with the needed assistance in order to complete scanning operations.

d. Only the Chief of HIMS or designee(s) will have permission to delete a scanned image from CPRS. A Deleted Image Placeholder will be scanned into CPRS when an image is removed.

e. The Chief Information Officer (CIO), Office of Information and Technology (OI&T) will be responsible for procedures to insure images are backed up and stored through multiple processes and can be restored should there be an event of catastrophic nature.

7. PROCEDURES:

a. Any document received by a scanning specialist, will be checked against the list of approved documents for appropriateness and then scanned. (Attachment A)

b. Each scanning specialist is responsible for maintaining a current list of approved documents that can be scanned. All scanned images will be concurrently monitored by each individual responsible for scanning to ensure that documents scanned into the patient’s electronic medical record are legible and accurate for clinical and administrative use.

c. If the scanning specialist is unsure of a document that has been identified to be scanned, or if it is not on the approved scanning list, the document will be referred to the Chief of HIMS or designee, for a decision on whether the document is appropriate for scanning.

d. If scanning specialist receives an illegible copy of a document it will be returned to originator with a request for a better copy. When a document is returned to the originator it will have a control number assigned and logged into a data base for tracking. Illegible

Center Memorandum 136-67, March 28, 2018 documents will not be scanned. Poor quality documents will be scanned with a coversheet that indicates the document is the best available copy.

e. Patient name and full Social Security Number will be on each page scanned.

Scanned documents will be annotated to identify that it has been scanned.

f. The Supervisor responsible for the scanning function of their service or their designee will train their staff on all scanning procedures to include the creation of administrative progress notes and conduct the quality assurance audits. All discrepancies in scanning should be followed up with each individual who has scanned the document.

When documents are entered into an incorrect patient record or under the wrong title, the Chief of HIMS or designee will be notified for proper action.

g. All original / source documents, once scanned, will be annotated to identify it has been scanned by placing a stamp in the lower right-hand corner of the document.

Documents will be disposed of properly (shredded), after verification of the image quality of the scanned documents, (see attachment D).

h. Contingency Plan for Computer Downtime: Should the electronic medical record (CPRS) be unavailable for greater than 4 hours, documentation completed during the time CPRS was not available will be scanned into the record, once CPRS is available.

i. The process to request a new form or outside documents to be considered for scanning is to send a copy of the form along with a request and reason the form should be added to the approved list to Medical Record Forms Sub-Committee for review/recommendation. Once reviewed/recommended, it will be forwarded to MRC for final approval.

8. INDEXING:

a. Documents scanned into Image Capture will have consistent index terms to allow for proper sorting and searching of scanned documents by clinicians and administrative staff. Administrative documents/images will be captured by attaching the scanned image to the appropriate administrative index.

b. Administrative documents scanned will be viewable by individuals who possess administrative access keys in Image Capture. The Clinical Applications Coordinator (CAC) must be contacted to request administrative access keys.

c. Once a standard document type has been approved to be scanned, indexing fields will be locked by creating configuration buttons in the Image Capture window to ensure that documents are consistently scanned into the proper category by every person scanning. In addition, individuals who are responsible for scanning should consult with the CHIMS and/or designee to determine what standardized configuration buttons have already been created for Image Capture.

9. DATA CAPTURE AND IMAGE LINKAGE:

Center Memorandum 136-67, March 28, 2018

a. Documents must be captured in Image Capture in a consistent manner and the integrity of the document must be maintained as in the paper medical record documents.

b. Images must be linked to the correct progress note for a specific visit date or by creation of a progress note (using appropriate verbiage and/or templates as approved by the MRC or equivalent committee) that is specific to the scanned document. If a progress note has been created to link an image to the note must be electronically authenticated by the individual who will be scanning the document or the individual who is responsible for the initial creation of the note. If the note remains unsigned, the image cannot be attached to the note and is not viewable.

10. REFERENCES: VHA Handbook 1907.01, current version Joint Commission Accreditation Standards

11. FOLLOW-UP RESPONSIBILITY: Chief, Medical Administration Service (136)

12. CONCURRENCE RESPONSIBILITY: Audiology; Dental; Geriatrics; Medicine;

Neurology; Nuclear Medicine; Nutrition and Food Service; Nursing; Pharmacy; Primary Care; Psychiatry; Psychology; Social Work; Surgery

13. RENEWAL DATE: March 28, 2022

Wade Vlosich Health Care System Director

Attachment A: Document Types Approved for Scanning Attachment B: Scanning Outside Medical Records Attachment C: Guideline for Scanning Purchase Card Attachment D: Quality Image Assurance Attachment E: Document Image Quality Assurance Monitor Attachment F: Deleted Image Placeholder

Center Memorandum 136-67, March 28, 2018

Attachment A

Document Types Approved for Scanning

Non-electronic information included in the scanned portion of the Patient’s Medical Record approved by the Medical Records Committee is as follows:

1) Advance Directives, Power of Attorney

2) Completed Medical Administration Forms to include but not limited to (Eligibility forms), VA Form 1010-EZ, DD214, Release of Information Forms

3) Any Progress notes and consents generated during any computer down time as described in the Contingency Plan for Computer Downtime.

4) Purchased Care Services

a) Non-VA Care Inpatient Record

b) Non-VA Care Outpatient Record

c) Non-VA Care ER Record

d) Non-VA Care Denied Inpatient Record

e) Non-VA Care Denied Outpatient Record

f) Non-VA Care Denied ER Record

g) Outside Clinical Documents

5) Outside Medical Documents from other non-VA care as deemed necessary by the clinician:

a) Discharge Summaries

b) H&P (most recent only)

c) Significant Consult Reports

d) Operation and Invasive Procedure Reports

e) Path/cytology and significant laboratory reports

f) Radiology reports

g) EKG’s

h) Emergency Room Notes

i) Transfer Notes

6) Flowsheets

7) Off-Station Reports

Center Memorandum 136-67, March 28, 2018

Attachment B

Scanning Outside Medical Records

1) Only pertinent portions of the outside medical record or those documents deemed appropriate for scanning by the clinician will be scanned. The clinician will indicate the date and title of the existing CPRS note to which the document will be attached.

If no appropriate note title can be identified, the document will be scanned using the CPRS note title of “Outside Clinical Documents”.

2) The scanning of outside clinical documents will only occur when accompanied by a Request to Scan Outside Medical Record Document(s) into Vista Image Form (Attachment C). This sheet will be scanned as the last page of the scanned document.

DESCRIPTION TIME FRAME

Advance Directive

Power of Attorney Discharge Summary Any within the last 3 years History & Physical Any within the last 3 years Consultations Any within the last 3 years

Laboratory Reports Any within the last 6 months Radiology Reports Any within the last 6 months

Operative /Invasive Procedure Reports Any and all Pathology Reports Any and all

3) Refer any questionable forms to your immediate supervisor prior to scanning.

4) Scanned documents will be disposed of properly (shredded) after verification of the scanned documents.

2. Only those portions of the Outside Medical Record document(s) identified by you the provider of care will be scanned into Vista Imaging. The remaining non-essential document(s) should be disposed of properly in locked shred containers or given back to the veteran.

OKC VA HCS Request to Scan Outside Medical Record Document(s) into Vista Image Procedure:

1. Clinically “filter” and sort the portions of the outside records you wish to have scanned.

2. Fill out all three sections below, A and C. Please choose on section C either (1) the existing CPRS Note to attach documents or (2) scanning the documents under the title “Outside Clinical Documents”.

3. Staple this Request to the document(s) to be scanned. Forwarded the information to Medical Records Department, Mail Stop (136D).

4. The document(s) will be scanned within THREE working days. If you need the document to be scanned immediately, please contact 405-456-1512 during normal business hours of 8:00 a.m. to 4:30 p.m.

Policy:

1. All clinical document(s) to be scanned in association with this request must be associated with one and only one progress note. Be sure to create this note so that the document(s) can be properly indexed. If you do not identify a specific progress note on this form, the HIMS default process will be to create a progress note entitled “Outside Medical Record Scanned” on the date of receipt of that record, and the record scanned in association with HIMS default settings.

3. Requests to scan documents other than Outside Medical Records must be made to the Medical Records Committee.

4. If the patient cannot be identified in this facility system of records, the document(s) will be returned to you.

5. To retrieve the information once scanned, first access Vista Imaging from the CPRS Tools Menu. With the CPRS notes tab showing, the blue icon next to the progress note of interest can be double-clicked to present the scanned documents. Inside VistA Imaging, scanned documents can be sorted by date and title by clicking on the column headers of the “Image listing” screen. If you have any questions, please call the Medical Records Department at Extension 6-1512.

ent)

36C25922R0102

A. Print your full name and Service, legibly written:

Number

Service Phone

Provider Signature Date Routing Code

B. Patient Full Name and Social Security Number:

C. (1) Date and title of existing CPRS note to which document will be attached:

Date:

Note Title:

Author, if not you:

(2) Note Title Not Needed: Scan under OUTSIDE CLINICAL DOCUMENTS (use only if no other existing appropriate CPRS note is available).

Note: Information to be scanned into the Clinical Record.

(This sheet will be scanned in as the last page of the docum

635-136D-001:02

Patient label (if available)

Attachment C Guideline for scanning Purchased Care

Section 1: Scanning in Fee Purchased Care Documents

a. Copies of reports submitted from outside sources, including physician notes, laboratory, x-ray, etc. must be scanned into the health record. Note: if Purchased Care documents are illegible, request legible copy from the originator before scanning.

b. Claims for travel expenses must be filed in the administrative portion of the record.

c. Paid fee claims are retained in the VistA Fee software package; therefore, a paper copy does not need to be filed in the administrative record nor scanned as an administrative document.

d. Non-VA documents for purchased care services should have an origin of “Fee.”

e. Only those external source documents that are authenticated 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. A summary progress note written by an appropriate clinician after a review of the external source document may be used in lieu of filing and/or scanning any external source document, therefore documents could be summarized according to VHA Handbook 1907.01.

f. Denied Purchased Care claims, ambulance records, and the associated documentation must be filed in the administrative record or scanned to an administrative document class. Denial of claims letters are archived on the server and can be downloaded when required.

Section 2: Consolidated Health Record

Below is a brief listing of the medical documentation, if received, which should be scanned, imported or filed in the health record for Non-VA Purchased Care provided.

a. Inpatient Records

• Inpatient admissions

Note: Facilities can prioritize the order of clinical documents within the inpatient stay so that pertinent clinical documents, such as Discharge Summary, H&P, and Operative Reports, are sequenced first and readily available to clinical staff.

To capture in Image Capture: Inpatient stay documents are scanned as a packet.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of discharge

• DOCUMENT IMAGE TYPE: MEDICAL RECORD

• SPECIALTY: Choose the specialty of the clinician, NOT the ward (Sometimes due to overflow a surgery patient is placed on a medicine floor but he is a SURGERY patient not a medicine patient. A medicine floor might have a mix of patients such as Cardiology, Pulmonary, Neurology, and Medicine.)

• PROCEDURE/EVENT: INPATIENT STAY

• IMAGE DESCRIPTION: Type in the hospital name for the inpatient stay

b. Ambulatory Surgery

• Operative report and pathology report (should receive pathology report whether negative or positive), i.e., within 48 hours.

To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of procedure

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: Choose the specialty of the clinician performing the surgery

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the ambulatory surgery

c. Anatomical, Surgical and Cytology Pathology

• Laboratory report and final result To capture in Image Capture:

• An order is placed in the VistA Anatomic Pathology package. If there is not an order, an order will need to be entered into the VistA Anatomic Pathology package. The image will be imported to the accession number assigned to that order in the Anatomic Pathology package.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date specimen was taken

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: LABORATORY

• PROCEDURE/EVENT: REFERENCE LAB

• IMAGE DESCRIPTION: Type in the facility’s name that performed the lab and the name of the specimen (body part, blood, etc.)

d. Consult

• Consult report To capture in Image Capture:

• Attach the captured document to the consultation.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of consult

• DOCUMENT IMAGE TYPE: CONSULT

• SPECIALTY: Choose the specialty of the clinician performing the service

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the consultation service

e. Dental

• Treatment plan and/or progress notes To capture in Image Capture:

• Attach the captured document to the consultation.

• ORIGIN: FEE

DOCUMENT IMAGE DATE: Date of procedure or date of last treatment on summary note

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROCEDURE RECORD/REPORT if there is not a consult

• SPECIALTY: Dentistry

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the dental service

f. Dialysis Notes

• Monthly summary notes with dates of treatment provided.

To capture in Image Capture:

• Attach the captured document to the appropriate dialysis title. If a note does not exist, the scanning clerk will need to create a note to attach the document to.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of last treatment on summary note

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROCEDURE RECORD/REPORT if there is not a consult

• SPECIALTY: NEPHROLOGY

• PROCEDURE/EVENT: DIALYSIS

• IMAGE DESCRIPTION: Type in the facility’s name that performed the dialysis and the date range of treatment.

g. Emergency Room Records

• ER Report

• Laboratory

• Radiology

To capture in Image Capture: Emergency Room documents should be scanned as a packet.

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create and capture to a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of ER visit

• DOCUMENT IMAGE TYPE: MEDICAL RECORD

• SPECIALTY: EMERGENCY MEDICINE

• PROCEDURE/EVENT: VISIT

• IMAGE DESCRIPTION: Type in the hospital name for the emergency room visit

h. Laboratory (not Anatomical Pathology)

• Laboratory report and final result To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create and capture to a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date specimen was taken

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: LABORATORY

• PROCEDURE/EVENT: REFERENCE LAB

• IMAGE DESCRIPTION: Type in the facility’s name that performed the lab and the type of laboratory test

i. Mammography

• Mammography Report - All external mammography reports must include a BI-RAD Assessment code in the impression of the final result. If no BI-RAD Assessment code is assigned, the facility is responsible for requesting the final report with the BI- RAD assessment code assignment by the external provider before sending the report to HIM for capturing in Image Capture. All contracts covering these services should annotate the requirement for BI-RAD in the required reports.

To capture in Image Capture:

• An order is placed in the VistA Radiology package. If there is not an order, an order must be entered into the VistA Radiology package. The image will be imported to the case number in the Radiology package.

• Radiology will import the image(s) and interpretation into Image Capture from the outside source or media, i.e., CD-ROM.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of mammography

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: RADIOLOGY or OBSTETRICS & GYNECOLOGY

• PROCEDURE/EVENT: MAMMOGRAPHY

• IMAGE DESCRIPTION: Type in the facility’s name that performed the procedure and the name of the procedure

j. Medical Oncology

• Summary report to include drug regimen, how often given, if interrupted.

To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of last treatment on summary note

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROCEDURE RECORD/REPORT if there is not a consult

• SPECIALTY: ONCOLOGY

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the oncology service and the date range of treatment.

k. Mental Health services

• Monthly summary notes with dates of treatment provided.

To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of last treatment on summary note

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROGRESS NOTE if there is not a consult

• SPECIALTY: MENTAL HEALTH, PSYCHIATRY OR

PSYCHOLOGY

• PROCEDURE/EVENT: VISIT

• IMAGE DESCRIPTION: Type in the facility’s name that performed the mental health service and the date range of treatment.

l. Outpatient Procedures

• Example – colonoscopy – procedure note, findings, and any final biopsy results.

To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of procedure

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: Choose the specialty of the clinician performing the service

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the outpatient procedure and the type of procedure performed

m. Outpatient Visit

• Progress note from outpatient visit To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create and capture to a Non-VA note

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of outpatient visit

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROGRESS NOTE if there is not a consult

• SPECIALTY: Choose the specialty of the clinician performing the service

• PROCEDURE/EVENT: VISIT

• IMAGE DESCRIPTION: Type in the facility’s name that performed the service

n. Procedure report and pathology report (excluding Anatomical Pathology)

• The procedure report and pathology report (should receive pathology report whether negative or positive), i.e., within 48 hours. If the procedure report and pathology report are received together, scan as indicated below. If the documents are received separately, scan separately as Pathology and Procedure as above.

To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of procedure

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: Choose the specialty of the clinician performing the procedure

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the procedure and the name of the specimen (body part, blood, etc.)

o. Radiation Therapy

• Summary report to include drug regimen, how often given, if interrupted, type of radiation, amount of radiation and location of treatment.

To capture in Image Capture:

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of last treatment on summary note

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROCEDURE RECORD/REPORT if there is not a consult

• SPECIALTY: RADIATION THERAPY

• PROCEDURE/EVENT: RADIATION THERAPY

• IMAGE DESCRIPTION: Type in the facility’s name that performed the radiation therapy and the name of the body part treated

p. Radiology

• Radiology Report To capture in Image Capture:

• An order is placed in the VistA Radiology package and registered to a “non-count” imaging location. If there is not an order, an order must be entered into the VistA Radiology package. The image will be imported to the case number in the Radiology package and a generic report entered utilizing the Outside Report Entry/Edit (RA Outside Rptentry) option.

• Radiology will import the image(s) and interpretation into VistA Imaging or other Image Capture from the outside source or media, i.e., CD-ROM.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of procedure

• DOCUMENT IMAGE TYPE: PROCEDURE RECORD/REPORT

• SPECIALTY: RADIOLOGY or NUCLEAR MEDICINE

• PROCEDURE/EVENT: Choose the appropriate procedure/event for the specialty selected from the drop-down menu in Image Capture

• IMAGE DESCRIPTION: Type in the facility’s name that performed the procedure and the name of the procedure

q. Rehabilitative Therapy Notes

• Monthly summary notes with dates of treatment provided.

To capture in Image Capture

• Attach the captured document to the appropriate title or consult for the service. If a note or consult does not exist, the scanning clerk will create a Non-VA note.

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of last treatment on summary note

• DOCUMENT IMAGE TYPE: CONSULT if there is a consult or PROGRESS NOTE if there is not a consult

• SPECIALTY: REHABILITATIVE or SPEECH PATHOLOGY

• PROCEDURE/EVENT: Choose the appropriate therapy, i.e., Physical Therapy

• IMAGE DESCRIPTION: Type in the facility’s name that performed the therapy and the date range of treatment.

Section 3: Administrative Record

1. Below is a brief listing of the administrative documentation, if received, which should be scanned, imported, or filed in the administrative record for Non-VA Purchased Care provided. Until there is an administrative tab in CPRS, sites that wish to file administrative documents electronically should create a document class for administrative documents.

Denied Non-VA claims and associated documentation should be scanned as a packet.

To capture in Image Capture:

• Attach to the Patient Only (Administrative)

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of service

• DOCUMENT IMAGE TYPE: DENIAL LETTER

• IMAGE DESCRIPTION: Type in the facility’s name that performed the service

Additional administrative documentation that should be scanned as administrative packets, not clinical include:

• Letters of Authorization for Care with supporting documentation.

• Letters of Appeal rights and supporting documentation.

• Notice of Disagreements

• Appeal Documentation to include Statement of Care, Supplemental Statement of Case, BVA Remand documents, etc.

To capture in Image Capture:

• Attach to the Patient Only (Administrative)

• ORIGIN: FEE

• DOCUMENT IMAGE DATE: Date of service

• DOCUMENT IMAGE TYPE: Correspondence IMAGE DESCRIPTION: Authorization for Care, Appeal rights, etc.…

2. TIMELINESS: All Non-VA Purchased Care documents should be imported into Image Capture within 5 business days of receipt. This will allow both clinical and administrative staff to view the image without delays.

Section 4: INDEXING QUICK REFERENCE GUIDE

ORIGIN

DOCUMENT

IMAGE DATE

DOCUMENT

IMAGE

TYPE

SPECIALTY

PROCEDURE

/ EVENT

IMAGE

DESCRIP

TION

CLINICAL DOCUMENTS

Inpatient Admission

Fee Date of Discharge

Medical Record

Select the specialty of the clinician

Inpatient Stay

Hospital name of inpatient stay

Ambulator y Surgery

Fee Date of Procedure

Procedure Record / Report

Select the specialty of the clinician

Choose the appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or another Image Capture

Facility name that performed the ambulatory surgery

Anatomic al, Surgical, Pathology

Fee Date specimen was taken

Procedure Record / Report

Laborato ry

Reference Lab

Facility name that performed the lab and name of the specimen

Consult Fee Date of Consult

Consult

Select the specialty of the clinician

Choose the appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or other Image Capture

Facility name that performed the consult

Dental Fee

Date of procedure or date of last treatment on summary note

Consult if there is a consult or Procedure Record / Report if there is not a consult

Dentistry

Choose the appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or other Image Capture

Facility name that performed the dental service

ORIGIN

DOCUMENT

IMAGE DATE

DOCUMENT

IMAGE

TYPE

SPECIALTY

PROCEDURE

/ EVENT

IMAGE

DESCRIP

TION

Dialysis Fee Date of last treatment on summary note

Consult if there is a consult or Procedure Record / Report if there is not a consult

Nephrolo gy

Dialysis

Facility name that performed the dialysis and the date range of treatment

Emergen cy Room Record

Fee Date of the ER visit

Medical Record

Emergen cy Medicine

Visit

Hospital name that performed the emergency service

Laborator y (excluding Anatomic al Pathology

Fee Date specimen was taken

Procedure Record / Report

Laborato ry

Reference Lab

Facility name that performed the lab and the type of laboratory test

Mammogr aphy

Fee Date of Mammograph y

Procedure Record / Report

Radiolog y or Obstetric s & Gynecolo gy

Mammography

Facility name that the service

Medical Oncology

Fee Date of last treatment on summary note

Consult if there is a consult or Procedure Record / Report if there is not a consult

Oncology

Choose the appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or Other Image Capture

Facility name that performed the service

Mental Health

Fee Date of last treatment on summary note

Consult if there is a consult or Progress Note if there is not a consult

Mental Health, Psychiatr y or Psycholo gy

Visit

Facility name that performed the mental health service and the

ORIGIN

DOCUMENT

IMAGE DATE

DOCUMENT

IMAGE

TYPE

SPECIALTY

PROCEDURE

/ EVENT

IMAGE

DESCRIP

TION

date range of treatment.

Outpatient Procedure s

Fee Date of Procedure

Procedure Record / Report

Select the specialty of the clinician

Choose the appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or Another Image Capture

Facility name that performed the outpatient procedure and the type of procedure performed

Outpatient Visit

Fee Date of Outpatient Visit

Consult if there is a consult or Progress Note if there is not a consult

Select the specialty of the clinician

Visit

Hospital name that the service

Procedure Report and Pathology report (excluding Surgical Pathology

Fee Date of Procedure

Procedure Record / Report

Select the specialty of the clinician

Choose the appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or other Image Capture

Facility name that performed the procedure and the name of the specimen (body part, blood, etc.)

Radiation Therapy

Fee Date of last treatment on summary note

Consult if there is a consult or Progress Note if there is not a consult

Radiation Therapy

Radiation Therapy

Facility name that performed the radiation therapy and the name of the body part treated

Radiolog Fee Date of Procedure Radiolog Choose the Facility

ORIGIN

DOCUMENT

IMAGE DATE

DOCUMENT

IMAGE

TYPE

SPECIALTY

PROCEDURE

/ EVENT

IMAGE

DESCRIP

TION

y Procedure Record / Report y or Nuclear Medicine appropriate procedure/event for the specialty selected from the drop-down menu in VistA Imaging or Other Image Capture name that performed the procedure and the name of the procedure

Rehabilita tive Therapy Notes

Fee Date of last treatment on summary note

Consult if there is a consult or Progress Note if there is not a consult

Rehabilit ation or Speech Patholog y

Choose the appropriate therapy, i.e., Physical Therapy

Facility name that performed the therapy and the date range of treatment.

ADMINISTRATIVE DOCUMENTS

Denied Non-VA Claims

Fee Date of Service

Denial Letter

N/A N/A

Facility name that performed the service

Authorizat ion of care, Appeal Rights, etc.

Fee Date of Service

Corresponde nce

N/A N/A Description of the document

Attachment D

Quality Image Assurance

1. PURPOSE: All scanned images will be concurrently monitored by each individual responsible for scanning to ensure that documents scanned into the patient’s medical record are accurate for clinical and administrative use. This process will also ensure compliance and adherence to the Oklahoma City VA Health Care System’s Document Scanning Policy and VHA Directive 1907.01 “Health Information Management and Health Records”.

2. PROCEDURES FOR CONDUCTING QUALITY ASSURANCE MONITORS:

a. Audits must be performed on every single document after an employee begins scanning without direct supervision, until no errors are found for five days (following initial training), or until the employee has scanned 100 documents error free.

b. The Supervisor responsible for the scanning function of their service will identify 10% of the total documents scanned or a minimum of 100 documents (if the 10% of documents scanned is less than 100) each month by using the Document Imaging Quality Assurance Monitor Tool (Attachment E). The documents will be monitored for proper and timely entry into CPRS, legibility of scanned document, correct entry into patients’ record, and the correct note title.

c. All discrepancies in scanning should be followed up with each individual who has scanned the document.

d. If the document is entered into an incorrect patient record, the Chief, HIMS or designee will be notified to delete the document from the wrong patient’s record and place the entry into the proper record. Attachment F will be used and scan into the place of the deleted document.

e. If the document is entered into the wrong title, the Chief, HIMS or designee will be notified for proper action.

f. If the document is illegible, the document will not be scanned, and returned to the requester for a legible copy.

g. Results of audits will be reported to the Medical Records Committee every third quarter. All reports must be submitted to the Chief, HIMS five working days before the end of third quarter by each department responsible for scanning.

h. When consistent problems are identified, focused reviews will be conducted that look at a higher volume of scanned documents. The errors must be investigated to determine the cause, scope, and seriousness; and an action plan must be implemented and reported to the Clinical Informatics Committee.

3. Guidelines for Conducting Quality Assurance Monitors

a. For Quality Monitoring purposes, the date the document was scanned, the department it was scanned in, and the staff who scanned the document can be retrieved through the client display portion of VistA Imaging: the abstract of the scanned image/document is pulled up, right click on it, and select the option “Image Information”.

b. Staff responsible for document scanning will review each image, to make sure that the demographic information is correct, the image is positioned as correctly as possible, and that all pages of documents have been capture in VistA Imaging.

c. The Quality Image Assurance Monitor Tool in Attachment E may be used for the supervisor to monitor the quality of documents scanned by his/her staff.

4. Guidelines for Reporting Quality Assurance Monitor Results

a. Quality Image Assurance Monitors are required to be reported to the MRC.

The following information must be reported to the committees: total number of documents/images scanned for the month, number of pending documents to be scanned, numbers of errors in scanning (i.e. records indexed incorrectly), number of images requested to be deleted (by Chief, HIMS or designee), and number of progress notes deleted (by Chief, HIMS or designee).

b. At the end of each month the Section Chief/Supervisor is required to conduct monitors on all employees who are responsible for scanning.

c. In order to determine which patients are selected for the monitor, the Section Chief/Supervisor is to take a random sample of documents that the employee has scanned, and if there have been any errors, or image deletions prior to the review the Section Chief/Supervisor should also conduct a monitor on those documents. Errors and image deletions should always be included in the Quality Image Assurance Monitors if there have been any errors.

d. The Document Imaging Quality Assurance Monitor will be reported in an Excel Spreadsheet titled “Document Scanning QA Monitor Tool” Attachment E.

5. Guidelines for Deleting Images

a. The Chief, HIMS or designee are the only individuals authorized to delete images from the VistA Imaging Capture and Display. Attachment F will be forwarded to the Chief of HIMS or designee to remove the document from the wrong patient’s record.

Attachment E Document Imaging Quality Assurance Monitor

Quarterly Ending: Reviewer:

Date of Review

Date Scanne d Last Name Last 4 SSN Document/Form Type Visit Date

Correc Pt. Nam Entere

? Y/N