D.5 HEALTHCARE PROVIDER MEDICAL RECORD DELINQUENCIES.pdf

D.5 HEALTHCARE PROVIDER MEDICAL RECORD DELINQUENCIES

36C25922R0102

DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SYSTEM

OKLAHOMA CITY, OKLAHOMA

Center Memorandum 136-55 June 20, 2017

Healthcare Provider Medical Record Delinquencies

1. SUMMARY: Center Memorandum 136-55 dated September 10, 2012 is reissued with minor changes.

2. PURPOSE: To establish a policy and procedure for assuring accurate and prompt completion of medical records at the Oklahoma City Veterans Affairs Health Care System (OKC VA HSC).

3. POLICY: It is the policy of the OKC VA HCS to adhere to VHA and The Joint Commission standards for timely documentation and completion of patient medical records.

4. SCOPE: This memorandum is applicable to all physicians, dentists, nurses, and healthcare practitioners e.g., nurse practitioners, physician assistants, certified nurse specialists, optometrists and technical health care professionals responsible for documentation and completion of the clinical medical record. For the purpose of this center memorandum they are all referred to as providers.

5. DOCUMENTATION REQUIREMENTS: The following must be completed in accordance with Medical Staff Bylaws;

a. A History and Physical Exam must be completed within 24 hours after admission.

b. Verbal orders and telephone orders must be authenticated within 24 hours.

c. Discharge Summaries, including AMA and death summaries, must be dictated within 24 hours of discharge.

d. Medical record documentation completion timeframes are contained within the Medical Staff Bylaws.

6. DELINQUENT OCCURRENCE LIST: A list generated by the Records Completion Section that tracks the number of inpatient and outpatient medical record delinquent occurrences by provider.

7. COMPLETION OF MEDICAL RECORDS MONITORING PROCESS: The specific items to be tracked for the delinquent reports are:

Center Memorandum 136-55, June 20, 2017

a. Dictation/CPRS documentation of all discharge summaries

b. Dictation of Operation/procedures reports

c. Unsigned/uncosigned progress notes

d. Unsigned orders

e. Inpatient medical records are to be completed within 30 calendar days as required by Joint Commission and the VHA standards. All documentation per this policy statement, and other policy statements referred to in this policy statement, must be followed in order to assure meeting this 30 calendar day standard or more specific Joint Commission/VHA standard (e.g.

dictation of operation report immediately after completion, dictation of discharge summary within 24 hours of discharge/death, etc.). The Health Information Management (HIMS) will provide each Service with a weekly delinquent dictation report and electronic bi-weekly delinquent signature report.

f. All medical records will be completed by the provider responsible for documenting the patients’ care in the record. In the event the documenting physician is unavailable to authenticate his/her records, and after efforts have been made to locate him/her, and the Service Chief is unable to authenticate the record(s) for the responsible physician, the medical record, upon recommendation of the Chief, Health Information Management Section, and approval by the Medical Records Committee, will be administratively closed.

g. All physicians leaving the medical staff (interns, residents, and attending physicians) must be cleared for record completion by the Manager, Health Information Management Section.

h. Records not completed by physicians prior to their departure will be assigned to a physician familiar with the case for signature and/or dictation.

Physicians will not be required to authenticate entries on an unfamiliar patient.

A physician may, however, summarize a course of treatment based on existing patient record documentation or review a discharge summary for consistency with existing patient record documentation if the original physician responsible for the patient’s care is no longer available to do so. In such cases, a notation is to be made in the record to indicate that the absence of the medical staff member responsible for the patient’s care and this entry is being made without personal knowledge of the patient. The completed summarization (discharge summary) will be authenticated by the medical staff member preparing the summary and/or the supervising physician.

8. SUBSEQUENT NOTIFICATIONS:

a. If incomplete medical record(s) occurrences have not been resolved within 30 days of the records becoming deficient, the Chairman of the Medical Records Committee will notify the providers (through their Service Chiefs) that they must complete their records within 48 hours or face disciplinary action, including suspension.

A copy of the notification will also be sent to the Chief of Staff.

b. If the provider still fails to complete their records, the Chief of Staff, may notify the provider’s program director and/or Service Chief that this individual is suspended from further clinical activity until delinquent records are completed.

c. If the provider has repeated suspensions for medical record delinquencies, the Chief of Staff, may consider:

(1) Entering into a written agreement with the individual to allow remediation of his/her delinquencies in a specific time period to avoid recurring suspensions of privileges; or

(2) Suspension of all privileges (and recommended disciplinary action to the Program Director) until delinquencies are resolved.

9. RESPONSIBILITIES:

a. The Chief of Staff, through each Chief of Service, is responsible for directing and supporting the efforts of the Chief of HIMS, to collect accurate, complete, and timely documentation from health care providers in accordance with OKC VA HCS Medical Staff Bylaws, VHA Rules, and Regulations and Joint Commission standards.

b. Service Chiefs (Clinical and Ancillary) are responsible for ensuring all documentation requirements stated in this policy are completed and authenticated by appropriate staff health care providers.

c. Medical Staff physicians are responsible for the management and documentation of the patient’s medical condition. The Medical staff member responsible for the patient’s care shall document supervision of care and treatment provided to patients by VA staff and allied health professionals.

d. The Chief of HIMS is responsible for the accurate collection and monitoring of all quantitative aspects of the medical record and ensuring the supportive objectives of the medical record are carried out in a timely manner.

10. REFERENCES:

a. Center Memorandum No. 136-48, Medical Record Committee

b. Center Memorandum No. 136-33, Medical Records Management

c. Medical Staff Bylaws, Rules and Regulations

d. Resident Supervision, VHA Handbook 1400.1

e. VHA Handbook 1907.01, “Health Information Management and Health Records dated March 19, 2015

f. The Joint Commission. Comprehensive Accreditation Manual for

Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2016.

11. FOLLOW-UP RESPONSIBILITY: Chief, Health Information Management

(136/HIM).

12. RENEWAL DATE: June 20, 2021

Vlosich, Kristopher W.

Digitally signed by Vlosich, Kristopher W.

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

Date: 2017.06.20 08:14:07 -05'00'

WADE VLOSICH

Health Care System Director