D.4 HEALTH INFORMATION MANAGEMENT.pdf

D.4 HEALTH INFORMATION MANAGEMENT

36C25922R0102

DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SYSTEM

Oklahoma City, Oklahoma

Center Memorandum 136-33 June 20, 2017

HEALTH INFORMATION MANAGEMENT

1. Summary: Center Memorandum 136-33, dated July 27, 2013 and Chg 1 CM 136-33 dated December 6, 2013 are rescinded. CM 136-33 is reissued with deletions and minor changes.

2. Purpose:

a. To establish policy and procedure for creation, completion, charge-out, control, retention, disposition, storage, protection, privacy, security and safeguarding the Consolidated Health Record (CHR) against loss, damage, destruction, tampering, and unauthorized access or use of medical records at the VA Health Care System (VA HCS), Oklahoma City, Oklahoma.

b. To establish procedures for approval of progress note templates.

c. To define policy and procedure for the definition, capture, analysis, transformation, transmission, release and reporting of individual patient-specific data/information related to the process(es) and/or outcome(s) of the patient's care at the OKC VA HCS.

d. All patient health care delivery (inpatient, ambulatory care, extended care, etc.) of the OKC VA HCS will be systematically documented; and the records thereof will be initiated, maintained, and processed for every individual assessed or treated.

The medical record incorporates information from subsequent contacts between the patient and the OKC VA HCS. Each record will be protected in such a manner to meet legal and clinical requirements of Department of Veterans Affairs (VA), applicable accrediting bodies, and in accordance with the policy contained herein. The medical record may consist of both electronic and paper components.

e. A medical record is ordinarily considered completed when the required contents, including hospital summary or final progress note, history and physical, and operative report, are entered into the electronic medical record and authenticated with all final diagnoses, any complications recorded. Incomplete records are considered delinquent 30 calendar days after discharge.

f. Entries in the medical record will be made by individuals given this right as specified in VA directives and/or facility policies as long as it is related to patient care.

3. Policy: A system of records is defined by the Privacy Act as any group of

Center Memorandum 136-33, June 20, 2017 records under the control of an agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other particular identifier assigned to the individual. All records retrieved in this manner must be maintained in a system of records identified by publication in the Federal Register. Maintenance of such records outside of a system of records may violate criminal law. The system of records recognized by the VA for recording of clinical documentation is the CHR, otherwise referred to as the medical record. Complete and accurate medical records are essential in providing quality patient care. A medical record is maintained for each patient. It contains the medical information necessary for the clinician to provide quality medical care to the patient. Since the medical record is the primary repository for clinical information, it is imperative that the location of every one of these records is accurately maintained at all times and that all original medical record documentation is contained in each record.

a. The CHR consists of the electronic medical record and the paper record, combined. Existing policies and procedures pertaining to paper medical records shall apply to computer generated medical records, including but not limited to, medical record delinquencies and deficiencies, responsibility for accuracy, authority to make entries, and making changes in the medical record. For specific information and guidelines concerning contingency plans for computer downtime, see OIT Standard Operating Procedures 08-16, Vista Catastrophe Contingency Recover all, OIT Standard Operating Procedures 08-38, Contingency Workstations and VHA Handbook 1907.01, Disaster Recovery Plan via Oklahoma City Veterans’ Affairs Health Care System (OKCVA HCS) Intranet Homepage.

b. For purposes of CHR maintenance and documentation requirements, ambulatory or outpatient care refers to all categories of care such as Community Based Outpatient Care (CBOC), Home Based Care (HBC), Outpatient , Ambulatory Care, etc.

c. All medical records are the property of the OKC VA HCS. A record may not be removed from the health care centers and VA's jurisdiction and safekeeping without a valid court order. Electronic records may be accessed by authorized personnel from remote locations.

d. CHR information, both paper documentation and electronic data is confidential information and will be safeguarded from unauthorized disclosure at all times. Request for CHR information from a patient, a representative of a patient, or agencies outside the VA will be directed through Release of Information Unit (ROI) within the Health Information Management Section (HIMS) of Medical Administration Service (MAS). These requests will be processed in accordance with Medical Center Memorandum 136-16, Release of Information from Medical Records and Veterans

Health Administration (VHA) Handbook 1605.1.

e. It is the policy of this HCS to maintain strict control, accountability, and availability of all medical records. The MAS Record Tracking computer system will be used to determine medical record location.

f. Medical records are indexed by name and social security number, maintained in terminal digit order, and stored in the Medical Record File Room (MRFR).

Information stored in an electronic medium, that is retrievable by patient name and social security number, is a part of the patient record.

g. No paper record will be locked inside a desk drawer, file cabinet, locker, or made inaccessible during its use by a borrower so it is not readily available at any time to authorized personnel. Tracking of a paper record will be done through the Vista MAS Record Tracking system.

h. Retention of medical records is determined by VHA Directive Record

Control Schedule (RCS) 10-1.

i. Only authorized personnel will be allowed access to the File Room or the electronic medical record.

4. Delegation of Authority and Responsibilities: The administrative management of medical records is the responsibility of MAS. The clinical management of medical records is the responsibility of each professional service contributing to the content of the medical record. The standards for medical records are those given by The Joint Commission, and in policies established by the VA

a. The Medical Records Committee participates in the overall management of the medical record and is responsible for 1) review and final approval of all proposed forms (paper) intended for placement in the CHR; ) approval of all 2) review and final approval of all documents to be scanned; 4) for oversight of the contents and quality of the medical record; and 5) reviewing the results of audits conducted by Clinical Services, Office of Quality, Safety, and Value and HIMS and recommending improvement actions based on those audits.

b. MAS Responsibilities: Chief, HIMS or his/her designee is responsible for maintaining the Medical Records File Room and safeguarding all medical and administrative records stored in that area; for the analysis, coding and transmission of data; for addressing requests by patients to amend/correct medical documents; for ensuring documentation meets qualitative standards; for monitoring requests and receipt of records from other VA or non-VA facilities; and for reviewing and recommending approval/disapproval of all forms developed for use in the CHR. The Chief, MAS, or his/her designee, is also designated as the system manager for Privacy Act purposes. The Chief, MAS will establish administrative procedures and controls to ensure that administrative support is adequate to foster the prompt preparation, signing and distribution of summaries. A weekly report of incomplete and delinquent discharge summaries and operative reports will be prepared and distributed to the Chief of Staff, clinical service chiefs and other concerned personnel. Providers who have delinquent records will be contacted by telephone by the HIMS. The Chief, HIMS is primarily responsible for medical record management, to include diagnostic and operative coding, in accordance with VA directives.

c. Service chiefs are responsible for establishing service policy that ensures confidential documents are disposed of in such a manner that confidentiality is protected; monitoring compliance of their staff regarding the security and integrity of electronic signatures and computer-generated medical documents including the completion of these documents; and management and use of order sets and templates within their service in accordance with the procedures outlined in this center memorandum.

d. Responsibility for the preparation of the discharge summary and operative report and their content rests exclusively with the member of the clinical staff having primary care responsibility for the patient. No standard length is prescribed, but the responsible clinical staff member should exercise judgment and present essential, pertinent data as clearly and concisely as possible. The chief of the service or attending staff physician/dentist will review the summary and indicate approval, by electronic and/or hand written signature.

e. Health Care Team Members are responsible for ensuring that all entries in the medical record are legible, coherent, in correct chronological sequence, dated, timed, and authenticated by its author. Notes made and signed by health care team members must be identified either by the use of the individual’s title, or by appropriate professional designation. All staff members who are authorized to use the Veterans Health Information Systems and Technology Architecture (VISTA) computer system for medical documentation are responsible for safeguarding electronic signature codes and computer-generated medical documents to prevent unauthorized use. Personnel whose duties involve documenting or processing medical records are responsible for accomplishing these duties according to VA and Joint Commission procedures and requirements.

f. Clinical Applications Coordinators (CACs) are responsible for implementation of electronic medical records. They ensure the appropriate use of all titles; and providing educational training to providers on the appropriate use of titles and the proper entry of the expected cosigner at the cosigner prompt. CAC’s are also responsible for reviewing all requests to scan documents to determine if the document can be otherwise captured in the Computerized Patient Record System (CPRS).

5. Maintenance and Availability of The Paper Medical Records: This is a multi-disciplinary responsibility. Each user of the medical record assumes responsibility for assuring the record is properly recharged to them, is kept secure, and that the record is timely returned to the Medical Records File Unit. Further, all medical center personnel, services, etc., are responsible for assuring that any loose filing generated by their service is scanned in a timely manner by the ward administration staff on the units or sent to the Health Information Management department. the . Under no circumstances will materials be held in excess of one (1) month.

See Attachment A for procedures in record requests, electronic charging/tracking of paper medical records. See Attachment B for procedures in the creation of the paper medical record, its forms/report types and content.

a. No medical record is to be locked in an office, file cabinet or hidden from plain sight. The Supervisor, Medical Records File Unit, with the assistance of the VA Police, may enter locked offices to retrieve missing and incorrectly charged medical records or search for records.

6. Protection of Records, Privacy, and Confidentiality: All information contained in the patient medical record is confidential, protected by law, and must be kept secure.

Medical records will not be removed from VA jurisdiction except in response to court order or statute.

7. Security:

a. Electronic signature codes are encrypted in the computer system. The computer system will not provide the code to anyone, including IRM staff. See Attachment E for procedures in Electronic Signatures, Corrections and Amendments to the Electronic Medical Record.

b. Records not returned to the Medical Record File Room will be maintained in an area secure from unauthorized access.

c. The MAS File Room will be secured and only authorized personnel will be admitted. Any employee, other than File Room personnel, needing access to the File Room, must obtain permission from the Chief, MAS or designee (i.e., Medical Record

Supervisor; Chief, HIMS).

8. Record Retention, Storage, and Disposal:

a. Electronic Retention: Medical record documents stored in VISTA, which are retrievable by patient identifier, are a part of the CHR. Printing of electronic and digitized (scanned) records at the time of retirement is not necessary when it is assured that the computerized system retention period is indefinite and when the quality control process assures that 1) the electronic and digitized records can be efficiently identified for authorized uses, 2) the images are retrievable and legible, and 3) that the integrity of digitized records is assured. Electronic and digitized (scanned) records are not purged.

Routine printing for filing and archive purposes will not be performed. Once scanned documents can be viewed across all VHA sites, printing will no longer be required.

b. Medical Records folders (CHR) are retained in the health care facility until

3 years after the last episode of care, at which time they become inactive. Inactive records are retired to the (FRC) as prescribed by National Archives and Records Administration (NARA). These records may be retrieved and reactivated as needed for patient care. If they are not reactivated by the accessioning facility, they are destroyed by witness disposal 72 years after retirement (75 years after the last episode of care).

c. The Master Patient Index identifies all patients who have ever been admitted to or treated by this facility. It is maintained on the VISTA and/or patient index cards that have been electronically stored.

d. Medical records will be maintained in an area that is unlikely to flood or be subject to damage from water or moisture. See Attachment C for procedures in protection of the medical record against fire and water damage.

e. Paper medical records will be stored in open shelf file units designed for medical records.

f. Paper medical records will not be stored on top of file shelving or on the floor.

g. Only those documents that cannot be created in or interfaced with the CPRS will be scanned. Scanned documents constitute an electronic file. A February 2003 NARA opinion granted VA the authority to destroy source documents after scanning, but only if record retention and retrieval requirements can be met, and quality control processes are in place. Imaged records must be retained for 75 years.

Photocopies of source documents may be destroyed after scanning as long as record retention and quality control processes are met (Please refer to Handbook 1907.01).

Source documents may also be retained if there is a compelling business reason to do so.

9. Disaster Recovery Plan for Patient Records: In the event of a disaster, patient records will be recreated based on available computer patient record information and/or hard copy records. If hard copy records are salvageable, they will be recovered. See Attachment C for procedures in recovery of water damaged medical records.

10. Medical Record Content: See Medical Staff Bylaws, Rules and Regulations and Attachment B of this CM. Health record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments and outcomes. The health record facilitates a) the ability of the health care professional to evaluate and plan the patient’s immediate treatment, and to monitor his/her health over time; b) communication and continuity of care among health care professionals involved in the patient’s care; c) accurate and timely claims review and payment; d) appropriate utilization review and quality of care evaluations; e) collection of data that may be useful for research and education; and f) accurate coding of diagnosis and procedures performed.

a. Copy and Paste Procedure:

(1) The electronic function of copy and paste is a powerful tool; however, this functionality must be used with caution and according to policy. Clinical, financial and legal problems may result when text is copied in a manner that implies the author obtained historical information, performed an exam, and/or documented a plan of care when he/she did not personally do it.

(2) Copying information from other documents in Vista is unnecessary duplication of information that does not assist those reading the record. Repeating information does not provide any advantage, but instead makes reading the charts more difficult and time consuming; copied portions of notes and other data is overwhelming to the reader and dwarfs the remaining information within the note.

(a) Copy and paste standards for OKC VA HCS:

(1) NEVER copy the signature block into another note.

(2) Never copy data or information that identifies a health care provider as involved in care that the health care provider is not involved.

(3) Do not copy entire laboratory findings, radiology reports, and other information in the health record verbatim into progress notes, consults or discharge summaries when it is not specifically addressed or clearly pertinent to the care provided.

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

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

(b) Accountability.

(1) The author is liable for the content of the information (including copied items) within the notes they authenticate. As part of the health record review function, use of copy and paste functionality will be monitored, reported to the Medical Records Committee, and where violations occur, findings will be reported to the appropriate Medical Staff. .

(2) Failure to comply with these standards may be deemed a violation of the Privacy Act requirement (5 U.S.C. Section 552a (e) (5)); VA conduct regulations (5 CFR Section 2635.101(b)(5)) - Employees shall put forth honest effort in the performance of their duties; 5 CFR Section 2635.705 - Employees shall use official time in an honest effort to perform official duties; and applicable affiliation agreements.

(3). Disciplinary action may be taken if violations of these standards are validated per VA Directive 5021, Employee Management Relations VA Directive 5021 that is maintained on the Office of Human Resources Management Web site

11. Reporting Requirements:

a. Monthly notices of incomplete and delinquent records, including ambulatory surgery, will be furnished by HIMS to the Chief of Staff, clinical service chiefs, and staff physicians. A listing of undictated operation reports is distributed weekly to Chief, Surgical Service. See Attachment D for procedures of the Records Completion Section (RCS) for analysis and completion of the medical record.

b. Residents who have rotated to OU Medical Center (OUMC) will be sent notices through the appropriate VA HCS Administrative Officer. House staff will be expected to return to the OKC VA HCS promptly to complete records.

c. The status of incomplete records will be reported to and monitored by the

Medical Records Committee

12. References: VHA Handbook 1907.01 Health Information Management and Health Records; RCS 10-1; the Privacy Act; HIPAA; VHA Handbook 1605.01 Privacy and Release of Information; VHA Handbook 1400.1, Medical Staff Bylaws, Rules and Regulations; JC Accreditation Manual for Health Care Organizations; MCM 136-10;

MCM 136-16; MCM 136-48; and Uniform Hospital Discharge Data Set (UHDDS).

13. Follow-up Responsibility: Chief, Medical Administration Service (136)

14. Renewal Date: June 20, 2021

Vlosich, Kristopher W.

Wade Vlosich

Digitally signed by Vlosich, Kristopher W.

DN: dc=gov, dc=va, ou=Entities, ou=InternalStaff, cn=Vlosich, Kristopher W.

Date: 2017.06.20 08:10:27 -05'00'

Health Care System Director

Attachments – A, B, C, D, and E

ATTACHMENT A

Requesting and Tracking Paper Medical Records

1. Return of Medical Records:

a. Research Projects: Records signed out for research projects may not be out of the File Unit longer than ten (10) workdays unless special arrangements have been made with the Supervisor, Medical Records File Unit.

2. Removal of the Paper Medical Records from VA Premises:

a. Medical records may be removed from the medical center’s jurisdiction and safekeeping only by court order, subpoena, or statute in accordance with VA regulations. All records are the property of the medical center and shall not otherwise be removed from VA premises without permission of the Director or his designee, the Chief, HIMS. Unauthorized removal of charts from the medical center is grounds for suspension of the clinical privileges of the practitioner for a period to be determined by the Clinical Executive Board (CEB). VA disciplinary action may also be invoked.

(1) Electronic copies will be printed to accompany the patient to the facility.

The confidentiality of the record shall be maintained.

ATTACHMENT B

Creation and Content of the Medical Record

Procedures:

1. Consolidated Health Record (CHR): The scope of the VA Health Care System expands the traditional concept of a patient record by using a CHR which consists of both the hard copy and the CPRS. The record should reflect honest and candid statements; derogatory or critical comments will be avoided. Individual employee names will not be included in the health record documentation unless the purpose is to identify practitioners for continuing care. The scope of documentation shall be comprehensive enough to provide continuity of care, be concise and complete, and reflect any treatment for service-connected condition(s), including agent orange, ionizing radiation, military sexual trauma or external contaminants and to support reported workload and billing for services.

a. Medical Record: The hard copy is known as the existing paper record. The computer-based patient record is the electronic patient record stored in the VISTA or other automated system using an electronic storage system (e.g., optical disk), that provides easy retrieval of complete, accurate and timely medical information. VISTA is the foundation for the computer-based patient record or CPRS.

b. Complete Medical Record: A complete medical record will have at least the following component parts: discharge summary, history and physical examination, progress notes, consultations (if any), pertinent laboratory and x-ray reports, operative and pathology report(s) (if appropriate), provider’s orders, vital signs, nursing care documentation and a copy of the death certificate (if appropriate). The component parts together contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

c. Administrative Record: An official record pertaining to administrative aspects of the care of a patient.

2. Documentation of all medical care (as required by VA and JC) is considered an essential means of communication between physicians and other professionals who contribute to patient care. Medical care documentation will encompass the initial filing of an application for admission or outpatient care and the generation of the entire medical record during the episode(s) of hospitalization or outpatient care. At the time of the treatment of the patient, an entry shall be made in the medical record documenting the care rendered. All appropriate staff are authorized to enter data into the medical record as long as it is related to patient care.

3. Medical records will be complete and include original signed documents relating to the patient’s treatment. Completeness implies that all required data is present and authenticated; all final diagnoses are recorded without use of abbreviations; and transcription of any dictated information is completed and inserted/uploaded into the record.

Examples include, but are not limited to, physicians, medical students, physician assistants, nurse practitioners, nurses, allied health practitioners, social workers, pharmacy technicians, medical support assistants, etc.

Notes made and authenticated by health care team members must be identified either by the use of the individual’s title, or by appropriate professional designation, e.g., Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Registered Nurse (RN), Registered Dietitian (RD), Licensed Practical Nurse LPN), Doctor of Philosophy (Ph.D.), Master’s Degree in Social Work (MSW), Physician’s Assistant (PA), Advanced Registered Nurse Practitioner (ARNP) or by the title of the professional service. Once affixed, authentication on electronic documents cannot be rescinded or repudiated.

Viewing unsigned notes is not allowed until such time as technology provides an audit trail of the note status.

CPRS users will respond promptly to View Alerts, which notify them of documents requiring authentication.

There will be sufficient recorded information to support the diagnoses and warrant the treatment and end results. The medical record will contain documentation of all clinical observations, including the results of therapy. Opinions requiring medical judgment must be documented or authenticated only by medical staff members, and other individuals who have been granted such clinical privileges.

Each entry in the record is authenticated as soon as possible after the preparation or completion of the entry. Authentication consists of the time (for physicians’ orders only), date, signature or initials and professional designation of the physician, dentist, or other responsible member of the interdisciplinary patient care team member making the entry and can include electronic signature.

Each entry will be legible. Legibility refers to the quality of penmanship used when recording data, including a clear, written signature, as well as content appearance of dictated, copied, and/or scanned information. Paper entries must be made in black ink to assure permanent recording. Handwritten entries are being phased out and should be limited to documents that technology cannot yet support.

4. A complete medical record will be maintained for each patient receiving inpatient and/or outpatient care at this medical center. Each document filed in the medical record will contain proper identification data that will consist of at least the patient’s name and social security number. If identification data are not available or are unattainable, the reason will be documented in the progress notes.

5. Temporary work pages or suspense notes, such as those maintained by social workers, physical therapists, occupational therapists, psychologists, and mental hygiene clinic therapists, may be maintained subject to the following conditions:

a. They are not maintained in a manner that constitutes a system of records under the Privacy Act of 1974 (see VHA Handbook 160501). The person creating the records is not doing so at agency direction.

b. They are absolutely uncirculated (they cannot be reviewed by anyone else, including secretaries and agency officials).

c. The decision to retain or destroy the notes is entirely the originator’s voluntary personal decision and not the decision of the agency. Such temporary work papers or suspense notes are not considered part of the CHR.

6. Symbols and abbreviations will be used in the patient record only when the Medical Records Committee has approved them with the concurrence of the Clinical Executive Board and the Chief of Staff. See the Medical Center Memorandum 136-10, The Use of Medical Abbreviations, for information on how to access the standardized list of abbreviations which is available to decipher the abbreviation’s meaning. This memorandum also lists unapproved symbols, abbreviations, and acronyms that will not be utilized in the medical record.

7. Documentation will be on standard and optional forms, computerized standard and optional forms, VA forms, and computerized versions mirroring VA forms, approved local overprints, approved local forms, and unnumbered computerized output (electrocardiogram, etc.). Requests for new forms and templates will be limited to those that can be developed in an electronic format. Duplicate copies of documents will not be filed in the CHR unless they bear notation of record value, in which case they will be scanned to ensure complete documentation of action taken.

8. Correction of errors in paper medical record documentation will be made by drawing a single line through the incorrect information without obliterating the original entry, with initials of the person correcting the error and the date of the correction. The correct information will be added, if appropriate, and a note made to indicate why the correction is necessary. The notation will be signed and dated by the person who documented the erroneous entry.

9. All medical records are confidential in nature. The privacy of patient records will be preserved, and the information they contain will not be accessible to or discussed with unauthorized persons. It is essential that all persons who have access to patient record information in the performance of their duties be informed of their duties and responsibilities in maintaining the confidentiality of privileged information. Any information released from the medical record will be done in accordance with VHA Handbook 1605.01, by authorized personnel and with required documentation of the release.

10. The basic elements of the medical record, guidelines for completion, and responsibility for entries are listed below:

a. Outpatient/Ambulatory Care Records: The medical record of each patient on ambulatory and/or outpatient care status who has three or more visits within a six-month period at a VA facility will have a problem list that consist of a list of known significant diagnoses, conditions, procedures, drug allergies and medications. The problem list is maintained in the CPRS in the Health Summary. The purpose of these reports is to enhance the continuity of care by providing a prominent location in which the patient’s past and present diagnoses, significant past operations, and the health care provider can readily review past and present medications. When maintained for an inpatient, there is no objection to the use of the same problem list for the patient who is being followed on ambulatory care and/or outpatient care services.

(1) Problem List and Medication Flow List:

(a) The Problem List and the Medication Flow List will be initiated by the third outpatient and/or ambulatory care visit to the health care provider and updated, as necessary, upon subsequent outpatient and/or ambulatory care visits.

(2) History and Physical Examination:

(a) When a patient is first admitted to VA care on an ambulatory and/or outpatient care level, a relevant history of the illness or injury and physical findings will be documented in the patient record.

(b) If a patient is on ambulatory/outpatient care status for a year, at the time of the next scheduled visit, the patient will be given an annual physical. The mental status of patients receiving mental health services must also be re-evaluated at the time of the annual physical. The examining practitioner must determine the comprehensiveness of the examination based upon the age, sex, and previous and current health status of the patient.

NOTE: If the examining practitioner is a resident, then the documentation needs to reflect that the patient was seen by or discussed with the supervising practitioner (see VHA Handbook 1400.01, Resident Supervision, for documentation requirements).

When care is no longer required, a summary note will provide for the condition on discharge, any patient instructions, and any relevant diagnoses, operations and findings.

(3) Ambulatory and/or Outpatient Progress Notes: A pertinent progress note will be documented at the time of each ambulatory and/or outpatient care visit. Each patient event will include or provide reference to: the chief complaint and/or reason for visit and, as appropriate, relevant history, examination findings, and prior diagnostic test results; assessment, clinical impression or diagnosis; plan for care; and date and legible identity of the health care professional; and appropriate risk factors will be identified.

The quality of the notes will be of the same caliber as inpatient requirements. Notations concerning broken appointments or termination of treatment will be made in the progress notes there must be a note by the staff practitioner of supervision or it is reflected in the resident’s progress note, which will include both the name of the staff practitioner and a summarization of the discussion.

b. Inpatient Care Records:

(1) History and Physical Examination:

(a) A complete History and Physical Examination will be completed by the physician within 24 hours of admission. In extended care, an H&P will be available within 72 hours of admission. A complete physical examination for a female will include breast and pelvic examinations. Acceptable reasons for deferral of either must be clearly documented on the Physical Examination form.

(b) When a patient is readmitted within thirty (30) days following the date of discharge for the same or a related condition, an interval history and physical examination noting any subsequent changes may be used in the medical record. The interval history and physical examination will be entered electronically, and will contain a statement that the previous history and physical examination have been reviewed.

(c) The interval history will also contain a statement containing any pertinent additions to the history and/or a statement indicating there is no change noted in the review of the previous history and physical examination.

(d) The H&P, whether for admission or surgery that is over thirty (30) calendar days old is not acceptable and a new H&P must be documented. In extended care, an annual H&P will be completed.

(2) Inpatient Progress Notes:

(a) Progress Notes will be entered electronically.

NOTE: Each Progress Note must be legible, coherent, and dates authenticated by its author. Notes made and signed by health care team members must be identified by use of the individual’s title or by appropriate initials; e.g., Medical Doctor (M.D.), Dentist (D.D.S.), Advance Registered Nurse Practitioner (ARNP), Registered Nurse (R.N.), Registered Dietician (R.D.), Licensed Practical Nurse (LPN), Doctor of Philosophy (Ph.D.), Master of Social Work (MSW), Physician’s Assistant (PA), or by title of the professional service.

(b) The attending physician will enter an admission progress note that is concise and reflect a discussion of the patient’s differential diagnosis.

(c) Resident supervision for inpatients will be documented by progress notes entered into the record by the staff physician according to VHA Handbook 1400.1, Resident Supervision. The attending physician must be identified by name.

(d) Interservice Transfer Progress Notes will be entered into CPRS. This note will be a concise recapitulation of the hospital course, to date, to include the indications for transfer, and be developed to assist the receiving unit, service, or medical staff member in providing continuity of patient care. The transferring physician prior to the patient’s transfer will complete this note.

(e) A discharge progress note will be documented for all patients released from care. It will contain date and type of discharge, diagnoses, discharge medications, recommendations relative to diet, exercise, limit of disability, condition at discharge (to include character of surgical wound, if appropriate), place of disposition, recommendations for follow up and patient education. Documentation for irregular discharges will contain, when applicable, the date and time of release, the reasons the patient left the medical center, if known, the condition of the patient when last observed, and that the patient was advised to remain to continue care.

(f) Progress notes will also be used to document certification of 21 days consecutive hospitalization, withholding or withdrawal of life-sustaining procedures, Advance Directives, seclusion and/or restraints, and summary of dental care.

(3) Required Inpatient Plans:

(a) Service Treatment Plan: A service treatment plan will be documented by each support service represented on the patient’s interdisciplinary team, e.g. nursing, social work, dietetics, etc., and by other disciplines that provide specialized services, i.e., speech and audiology, rehabilitation, etc.

Treatment plans for each support service or specialized service will be entered in CPRS, or Nursing Documentation VA Form 10-0096. The treatment plan documented by each support service or specialized service will be authenticated by its author. In extended care, the initial treatment plan is documented within 14 days of admission; a plan of care is developed no later than one week after the initial assessment; i.e., within 21 days after admission. The care plan is evaluated when there is significant change in the condition of the patient or at least every 90 days for extended care.

(b) Discharge Plan: A discharge plan will be documented for all patients.

The discharge planning process will be initiated as soon as possible following admission of the patient. Discharge Planning will be accomplished in accordance with Medical Center Memorandum 136-30, Patient Discharges and Planning Change 1.

(4) Doctor’s Orders (VA Form 10-1158):

(a) Diagnostic and therapeutic orders will be written only by physicians and dental medical staff members, and house staff (physicians and dentists in training status, and by Physician Assistants (PA) and Certified Registered Nurse Anesthetists (CRNA) as defined within the scope of practice statements and within the authority of their clinical privileges. Recording of doctor’s orders will be legible, and include signature, and date and time written (initials are not acceptable). Verbal orders should only be accepted in urgent or emergent circumstances. Verbal/telephone orders may be accepted and transcribed by Registered Nurses only, with the following exception: For respiratory/ pulmonary patient care, verbal/telephone orders can be accepted and transcribed by Registered Respiratory Therapists (RRT) and Certified Respiratory Therapy Technicians (CRTT).

(b) All telephone orders should be authenticated by the prescribing practitioner or designated attending on the appropriate service prior to the patient being discharged.

(c) Extended Care program orders will be reviewed/rewritten monthly.

Provided no changes are made to the orders, the monthly review may be documented by simply writing “continue” or “renew.”

(5) Operations and Procedures:

(a) All operations and invasive procedures will require a properly executed

Informed Consent, which must be obtained by the physician prior to performing the procedure or surgery. The fact that the patient has been provided appropriate information and counseling and that he/she has consented to the proposed procedure/treatment should be noted in the progress notes of the patient’s medical record. Please refer to CM-11-10 and VHA Handbook 1004.01 for documentation of the informed consent process for treatment and procedure that require signature consent must include specific elements.

(6) In certain specific situations, as noted below, documentation of the consent, and the fact that the consequences of such refusal or revocation were discussed with the patient, will be notated in the record.

(a) Require the use of sedation.

(1) Require narcotic analgesia or anesthesia.

(2) Are considered to produce significant discomfort to the patient.

(3) Have a significant risk of implication or morbidity.

(4) Require injections of any substance into joint space of body cavity.

(b) The pre-anesthesia note completed by the Anesthesiologist/ Anesthetist should include pertinent information relative to the choice of anesthesia and the surgical procedure anticipated, the patient’s previous drug or anesthetic experiences, and any potential anesthetic experiences, and any potential anesthetic problems. In an extreme emergency this entry may be deferred; however, reasons for deferral must be clearly documented.

(c) A record of all pertinent events taking place during the induction and maintenance of anesthesia, including the dosage and duration of anesthetic agents, other drugs, intravenous fluids, and blood components, will be made a permanent part of the patient’s record.

(d) Operative reports are to be dictated, transcribed and entered into the electronic medical record immediately after surgery and will describe the findings, the technical procedures used, and the specimen(s) removed, the postoperative diagnosis, and the name of the primary surgeon and any assistants and indicate the presence and/or involvement of the attending surgeon in the body of the report. The completed operative report will be authenticated by the surgeon and filed into the electronic medical record as soon as possible after surgery. When the operative report is not placed in the electronic medical record immediately after surgery (for example, there is a transcription and/or filing delay) an brief operative progress note is entered into the electronic medical record immediately after surgery to provide pertinent information for any individual required to attend to the patient.

(e) Level of Supervision: The “level” of supervision of such procedures will be documented within the Surgical Package according to the following:

(1) Level 1. Staff physician is physically present and directly involved in the procedure.

(2) Level 2. Staff physician is present and available for consultation.

(3) Level 3. Staff physician is immediately available for consultation and support via telephone or other telecommunication device, and is available in person in a reasonable period of time.

(f) At least one post anesthesia note is required from the Anesthesiologist/

Anesthetist. This note must describe the presence or absence or anesthesia related complications.

(7) Discharge Summary:

(a) A discharge summary will be prepared for every patient released from inpatient care and will be dictated by the physician at, or near, the time of discharge.

Medical Records of discharged patients will be completed within thirty (30) days. The Health Information Management Section will publish a listing of delinquent dictations at least weekly.

(b) The principle diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. All other diagnoses, conditions and situations that exist at the time of admission or develop subsequently which affect the treatment received or the length of stay, will be documented on the summary in descending order of clinical importance.

Diagnoses and other clinical conditions noted, but not treated, which did not impact the length of stay or affect the treatment received, may also appear on the Discharge Summary. The medical staff member who prepares the discharge summary will document all significant procedures. A significant procedure is one that is surgical in nature, carries a procedural risk (including traumatic or physiologic risks), carries an anesthetic risk, and/or requires specialized training.

The attending staff physician, dentist, or chief of service will review the summary and indicate approval by authentication.

(c) The narrative portion of the summary must include the following:

(1) The reason for admission, status of the patient on admission, and the results of diagnostic tests ordered at the time of admission.

(2) The treatment and procedures performed during the episode of care.

(3) The patient’s response to the treatment and procedures used during the episodes of care.

(4) The status of the patient at release from the episode of care.

(5) The instructions given to the patient, or others, for the post discharge period (diet instructions, medications and dosages, activities permitted or limited, date for return to work or other post-hospital activity, period of convalescence, arrangements of follow-up, etc.).

(8) A final progress note may be used in lieu of a discharge summary for those patients with problems and interventions of a minor nature (as defined by the medical staff) who require less than a 24-hour period of hospitalization. Documentation must contain those items required in the JC standards (i.e., reason for hospitalization, significant findings, procedures performed and treatment rendered; patient’s condition on discharge, and any specific instructions given to patient and/or family as pertinent

(9) Autopsies: After completion of the autopsy, the preliminary gross interpretation will be dictated, transcribed, authenticated, and filed in the electronic medical record within 72 hours. Final autopsy protocols will be completed, authenticated, and filed within 60 days after the date of death.

9. Creating Records:

a. Medical and/or administrative records are created by Ambulatory Care & Processing Section upon registration/disposition of a new patient.

10. Special Reports: Patients often require special reports for rating purposes requested by Adjudication Division, VA Regional Office. These requests must be complied promptly as delay may adversely affect the patient and benefits that he/she or his/her family might be entitled to receive. Special reports requested may include:

a. 21-day Certification: The physician will be asked to review the treatment provided and determine if hospitalization is required for the service-connected disability listed on the request. If hospital treatment is required, a progress note stating this is required will be written with action noted on the request.

b. Competency Report: An entry will be made in the progress notes and on the form provided regarding the patient's ability to manage his funds or take care of his affairs, as appropriate.

c. Special Reports for Rating: These reports are made when the patient is hospitalized and a more detailed report of a special condition is needed. Consultation will be requested, if necessary, to fulfill the request.

d. Aid and attendance (VA Form 21-2680): This form will be completed when requested.

e. NSLI Government Life Insurance Form: NSLI Form to show disability for waiver of premium will be completed by treating physician when requested.

f. Reports may be forwarded on the initiative of the hospital to report a change in competency or to report a need for aid and attendance.

11. Computerized Based Medical Records:

a. Legal Consideration: The electronic signature will appear on computer-generated medical record documents to authenticate and/or countersign medical record entries. These documents may include, but are not limited to consults, progress notes, discharge summaries, reports of procedures and patient-related orders, excluding Schedule II drugs. The electronic signature will be treated as a written signature with all ethical and legal implications thereof.

b. Access Codes: Each person authorized to make entries in the hard copy medical record will be authorized to utilize electronic means of authenticating information in the medical record. After being granted access, the CAC will authorize a computer flag (security key).

c. Provider Key: The provider key will be assigned to health care providers whose signature code must be entered when the provider electronically signs reports, orders and other electronic medical record entries and to change the electronic code itself. If the provider orders medications, Information Management (IM) will assign privileges upon authentication.

d. Security: Electronic Signature codes are encrypted in the computer system.

The computer system will not provide the code to anyone, including IM staff.

ATTACHMENT C

Security and Integrity of Medical Records from Fire, Water Damage and Moisture

1. No medical records will be left un-attended for any reason; i.e. carts with medical records left in hallways of common areas.

2. Medical Records are maintained in Garrison Tower Building Suite B200 and B230.

3. Safety features of Medical Records include four (4) fire extinguishers located in the following areas:

a. Entrances and Exits of Medical Record office B200 and in Release of Information

Area office B230.

4. Medical Records also is equipped with automatic sprinklers.

5. In the event of fire and activation of the automatic sprinkler system the action taken will be as stated in Water Damaged Medical Records below.

6. Water Damaged Medical Records will be bagged and delivered to a local vendor (bound by confidentiality by contract) for freeze-drying the wet records. This process will prevent molding. This will facilitate scanning of these records. Scanning will be accomplished on white bond paper. This will allow for recovery of the medical information to be filed in a reconstructed CHR. The image will be scanned into the CPRS for electronic storage and retrieval.