D.5 HEALTHCARE PROVIDER MEDICAL RECORDS DELINIQUENCIES2.pdf

D.5 HEALTHCARE PROVIDER MEDICAL RECORD DELINQUENCIES

36C25922R0102

Procedures for Healthcare Provider Medical Record Delinquencies

SOP 136-002

Oklahoma City VA Health Care System Oklahoma City, OK

Signatory Authority:

Chief, Medical Administration Service

Responsible Owner:

Chief, Health Information Management

1. PURPOSE AND AUTHORITY

Service Line(s)

Medical Administration Service

Effective Date:

December 12, 2022

Recertification Date:

December 31, 2027

The purpose of this standard operating procedure (SOP) is to establish procedures for ensuring accurate and prompt completion of medical records at the Oklahoma City VA Health Care System (OKCVAHCS).

This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 1907.01 VHA Health Information Management and Health Records, dated April 5th, 2021; facility Medical Staff Bylaws, and Joint Commission requirements.

1. PROCEDURES

a. Documentation Requirements – The following must be completed in accordance with Medical Staff Bylaws:

(1) A History and Physical Exam must be completed within 24 hour following admission.

(2) Verbal orders and telephone orders must be authenticated within 24 hours.

Written orders must be authenticated within 24 hours.

(3) Discharge summaries, including AMA and death summaries, must be completed and signed within 2 business days of discharge (3 business days for CLC discharges).

(4) Progress notes must be completed and signed within 3 business days.

(5) Inpatient medical records are to be completed within 30 calendar days as required by Joint Commission and the VHA standards. All documentation per this procedure must be followed in order to ensure meeting this 30 calendar day requirement (e.g. dictation of operation report immediately after completion, dictation of discharge summary within 24 hours of discharge/death, etc.).

December 12, 2022 SOP MAS-002

(6) 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.

(7) All providers leaving the medical staff must be cleared for medical record completion by the Chief, HIMS/designee.

(8) Medical records not completed by providers prior to their departure will be assigned to a provider familiar with the case for signature and/or dictation. Providers will not be required to authenticate entries on an unfamiliar patient. A provider 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 provider 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 provider.

b. Delinquent Medical Records Monitoring – The following items will be monitored for completion and reported weekly if not completed:

(1) Undictated discharge summaries

(2) Undictated operative reports

(3) Unsigned and un-cosigned progress notes, discharge summaries and operative reports.

(4) Unsigned orders

c. Notifications

(1) Weekly notifications of delinquent items listed in 1.b above will be sent to Service Line Chiefs and Administrative Officers for action.

(2) If incomplete medical record(s) occurrences have not been resolved within 30 days of the records becoming deficient, the Chairperson 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.

(3) 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.

(4) If the provider has repeated suspensions for medical record delinquencies, the Chief of Staff, may consider:

(a) 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

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

2. ASSIGNMENT OF RESPONSIBILITIES

a. This SOP 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 SOP they are all referred to as providers.

b. Chief of Staff – through each Service Chief, is responsible for directing and supporting the efforts of the Chief, HIMS, to collect accurate, complete, and timely documentation from health care providers in accordance with OKCVAHCS Medical Staff Bylaws, VHA Directives and Joint Commission standards.

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

d. Medical Staff Physicians – 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.

e. Chief, HIMS – 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.

3. REFERENCES

a. VHA Directive 1907.01 VHA Health Information Management and Health Records, April 5, 2021

b. Medical Staff Bylaws, FY 2021

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c. Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2022.

4. REVIEW

At recertification, when there are changes to the governing document, and any regulatory requirement for more frequent review.

5. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of December 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

6. SIGNATORY AUTHORITY

MANDEEP S.

Digitally signed by MANDEEP

S. BHULLAR 513806

BHULLAR 513806 Date: 2022.12.12 15:55:19

Mandeep Bhullar Chief, Medical Administration Service Date Approved: December 12, 2022

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available at: - (sharepoint.com) https://dvagov.sharepoint.com/sites/okl/Memos/default.aspx