D.17 VHA HIM Health Record Documentation Program Guide Version 1.1 - ATTACHED.pdf

VHA HIM

Health Record Documentation Program Guide Version 1.1

Dated: November 29, 2022

This Veterans Health Administration (VHA) Health Information Management (HIM) Health Record Documentation Program Guide establishes processes and procedures for managing health records and ensuring health record documentation is complete, accurate, timely, clinically-pertinent, and readily-accessible to serve as a basis to plan patient care, support diagnoses, warrant treatment, measure outcomes, support education, research, and facilitate performance improvement processes and legal requirements.

VHA Handbook 1907.01, HIM and Health Records, dated March 15, 2015, has been rescinded and replaced with VHA Directive 1907.01, this Health Record Documentation Program Guide, other corresponding HIM Program Guides, and other VHA Directives.

The content within this program guide reflects current state, VistA/CPRS health record documentation guidance and is not fully electronic health record system agnostic yet with Oracle Cerner specifications.

The VHA HIM Program Office (105HIG) is responsible for the contents of this Program Guide and will provide updated versions as needed when new health record documentation guidance becomes available. Questions may be referred to the HIM Program Office Staff mail group:

VHAHIGHIMVAStaff@va.gov.

D.17 VHA HIM Health Record Documentation Program Guide Version 1.1

D.17 VHA HIM Health Record Documentation Program Guide Version 1.1 - 36C26225R0004 mailto:VHAHIGHIMVAStaff@va.gov

Dated: November 29, 2022

Document Version History

Document Revision Effective Date Description Version 1.1 November 29, 2022 Updated the Surgery and Procedures section by adding the following: definitions for pre-operative, intraoperative, and post-operative.

Addition of Complications documentation guidance. (Based on OIG Findings/Recommendations)

Dated: November 29, 2022

CONTENTS

PARAGRAPH PAGE

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. RESPONSIBILITIES

5. MANAGEMENT OF HEALTH RECORDS

6. ACCESS TO HEALTH RECORDS AND HEALTH INFORMATION

7. DOCUMENTATION STANDARDS

8. TIMEFRAMES

9. AUTHORIZED ENTRIES IN HEALTH RECORDS

10. AUTHENTICATION

11. COMPLETE AND INCOMPLETE RECORDS

12. HEALTH RECORD ALTERATIONS AND MODIFICATIONS

13. TRANSCRIPTION, DICTATION AND SPEECH RECOGNITION

14. ENCOUNTER FORMS

15. HEALTH RECORD DOCUMENTATION

a. Electronic Health Record

b. Standards of Electronic Notes

c. Clinical Postings

d. Electronic Signatures

e. Evaluation and Management (E/M) Services

f. Emergency and Urgent Care

g. Outpatient or Ambulatory Care

h. Inpatient Health Care

i. Resident Supervision

j. Initial Assessments

k. History and Physical

l. Re-assessments

Dated: November 29, 2022

m. Treatment Plan

n. Care Plan

o. Laboratory and Imaging

p. Progress Notes

q. Commitment

r. Seclusion and Restraint

s. Inter-service or Inter-ward Transfer Note

t. Inter-facility Transfer

u. Clinician to Clinician Shift Handoff

v. Discharge Summary, Discharge Progress Note and Discharge Instructions

w. Consultation and Referrals

x. Informed Consent

y. Anesthesia

z. Surgery and Procedures

aa. Orders

bb. Advance Directive

cc. State Authorized Portable Orders

dd. Observation

ee. Autopsy

16. EMPLOYEE HEALTH RECORDS

17. RESEARCH

18. EXTERNAL SOURCE DOCUMENTS

REFERENCES

Dated: November 29, 2022

VHA HEALTH INFORMATION MANAGEMENT

HEALTH RECORD DOCUMENTATION PROGRAM GUIDE

1. PURPOSE

This Veterans Health Administration (VHA) Health Information Management (HIM) Health Record Documentation Program Guide provides guidance for effectively managing the requirements of health information and health record documentation within VHA.

NOTE: VHA Directive 1907.01 is to be utilized in conjunction with this program guide.

2. BACKGROUND

a. Under Title 44 United States Code (U.S.C.) 3102(1), VHA, by statute, must maintain complete, accurate, timely, clinically pertinent, and readily accessible patient health records, which contain sufficient recorded information to serve as a basis to plan patient care, support diagnoses, warrant treatment, measure outcomes, support education, research, and facilitate performance improvement processes and legal requirements.

b. The most current standards of The Joint Commission must also be followed, unless specifically otherwise stated.

c. The health record must be standardized with regard to content, creation, maintenance, management, processing, and expected quality measures. Electronic capture and storage of patient health information must be implemented to enhance access to patient data by health care practitioners and other authorized users. Electronically stored and printed patient information is subject to the same medical and legal requirements as handwritten information in the health record.

d. The privacy and security of patient information stored in any media must be protected in accordance with, but not limited to: the Privacy Act of 1974 (5 U.S.C. 552a), the Freedom of Information Act (5 U.S.C. 552); Federal Information Security Management Act (44 U.S.C.

3541); Office of Management and Budget (OMB) Circulars A-123 and A-130; VA Directive and Handbook 6500 Managing Information Security Risk: VA Information Security Program;

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules (Title 45 Code of Federal Regulations (CFR) 160, and 164); VHA Handbook 1605.1, Privacy and Release of Information; and The Joint Commission standards for privacy and security.

e. In accordance with Department of Veterans Affairs (VA) Handbook 6500, regarding the Information Security Program, local safeguards must be established concerning patient record security and confidentiality.

3. DEFINITIONS

Dated: November 29, 2022

a. Addendum. An addendum is the inclusion of additional information to a source document.

b. Authentication. Authentication is the provision of assurance of an entity’s identity.

Such assurance requires association of the entity with a secure identifier, such as a written signature, written initials, or electronic signatures. Authentication can be used in the following contexts:

(1) To authorize or validate an entry in a health record.

(2) To corroborate that the source or sender of the data received is as claimed, and to provide assurance of the claimed identity of the entity or receiver.

c. Clinical Documentation Integrity. Clinical Documentation Integrity (CDI) is a process where the health record is manually reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation.

d. Coding. Coding is the process of assigning alphanumeric characters (alpha, numeric, or a combination of both) from a recognized and approved coding classification system that properly identifies and defines medical services, procedures, and diagnoses. Coding performed by HIM staff include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System

(HCPCS).

e. Collateral. A Collateral is a person, related to or associated with a Veteran receiving care from VA. The person is seen by a professional member of the Veterans Affairs (VA) medical facility's staff, either within the facility or at a site away from the facility, for reasons related to the Veteran's clinical care.

f. Collateral Record. The Collateral Record is a legal health record that documents any aspect of health care and services provided to a Collateral of a Veteran. Records of family members or significant others (also called collaterals) are not to be included in the patient’s health record. The collateral (spouse, family member, or significant other who receives services relative to the patient’s care) is to be entered for use in all encounters provided directly to the collateral and reporting using the collateral’s name as the person who received the services, not under the patient’s record. If there is pertinent clinical information relative to the Veteran’s health, those family members or significant other records should be summarized without use of names or other identifiers.

g. Consult. A consult is a specific document, most often electronic, which facilitates and communicates consultative and non-consultative service requests and subsequent activities.

Dated: November 29, 2022

h. Designated Record Set. HIPAA defines “designated record set” as: A group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider; [or] (iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals. The legal health record is a subset of the designated record set.

i. Disclosure. Disclosure is the release, transfer, provision of access to, or divulging of information in any manner outside VHA.

j. Health Record. A health record includes the electronic health record (EHR) and the paper record, combined, and is also known as the legal health record. A health record can be comprised of two divisions, which are the following:

k. Administrative Health Record. The administrative health record is an official record pertaining to the administrative aspects involved in the care of a patient, such as: demographics, eligibility, billing, correspondence, and other business-related aspects.

l. Clinical Health Record. The clinical health record is the documentation of all types of health care services provided to an individual, in any aspect of health care delivery. A clinical health record includes; individually identifiable data, in any medium, collected and directly used in or for documenting health care. The term includes records of care in any health-related setting used by health care professionals, while providing patient care services, to review patient data or document their own observations, actions, or instructions. The clinical health record includes all handwritten and computerized components of the documentation.

m. Health Record Review. A health record review is the process of measuring and assessing to improve the quality of health record documentation. Health record review evaluates the degree to which health record documentation is accurate, complete, and performed in a timely manner. This process is carried out with the cooperation of relevant departments or services. The function includes the oversight of the development of document titles, computerized templates, overprinted forms, order sets, boilerplates, and note titles for standardization in the health record.

n. Incomplete Health Record. An incomplete health record is a patient health record missing content, reports, or authentications.

o. Inpatient. An inpatient is a recipient of medical services who is admitted to a VA medical facility and receives health care services, room, board, and continuous nursing service in a unit or area of the hospital where patients generally stay overnight. NOTE: This excludes admission for observation.

p. Legal Health Record. The legal health record is the documentation of the health care services provided to an individual in any aspect of health care delivery by a health care

Dated: November 29, 2022 organization. The legal health record is individually identifiable data, in any medium, collected and directly used in or for documenting health care or health status.

q. Medical Staff Member. Medical staff members are physicians and dentists, or other licensed individuals, including Physician Assistants (PA) and Advanced Practiced Registered Nurses (APRN), permitted by the VA medical facility's by-laws to provide patient care services independently (i.e., without supervision or direction).

r. Mental Health Residential Rehabilitation Treatment Program. Mental Health Residential Rehabilitation Treatment Program (MHRRTP) is the umbrella term for programs that provide residential rehabilitative and clinical care to Veterans who have a wide range of problems, illnesses, or rehabilitative care needs (i.e., mental health, substance use disorder, co-occurring medical diagnosis, homelessness, vocational, educational, or social).

s. Need-to-Know. Need-to-know is access to health information by authorized clinical or administrative users based on the user's role and a specific reason the information is needed to perform the user's job function.

t. Note Title. The note title is the designation given to an electronic document in the EHR or a paper form that enables a user to retrieve information from the health record.

u. Observation Patient or Status. An Observation patient is one with a medical, surgical, or mental health condition showing a sufficient degree of instability or disability that needs to be monitored, provided with short term treatment, and re-assessed before a decision is made whether the patient requires further treatment in an acute care inpatient setting or can be discharged or assigned to care in another setting. An Observation status bed is a bed in the VA medical facility either in an outpatient location such as the Emergency Department (ED) or Urgent Care Clinic (UCC), or in an inpatient location designated as a non-count ward, where patients with medical, surgical, or mental health conditions can be kept for extended monitoring, evaluation, and treatment. Any acute bed, including Intensive Care unit beds, can be used for Observation status. NOTE: See VHA Directive 1036, Standards for Observation in VA Medical Facilities.

v. Outpatient. An outpatient is a recipient of health care services who is not admitted to a bed.

w. Patient. A patient is the recipient of VA health care. Veterans admitted to CLC care units and MHRRTP units may also be referred to as “residents.” For the purposes of this document, CLC and MHRRTP residents are included when referring to “patient.”

x. Patient Care Encounter. Patient Care Encounter (PCE) is a data repository that captures clinical data resulting from ambulatory care patient encounters.

Dated: November 29, 2022

y. Patient Postings. Patient postings are a component of the EHR that includes messages about patients. NOTE: This is an expanded version of Crisis, Warning, Adverse Reactions/Allergies and Directives (CWAD).

z. Patient Treatment File. Patient Treatment File (PTF) is an Automatic Data Processing system for inputting, maintaining, and presenting personal, demographic, and clinical data related to care and treatment episodes of individuals who are patients or members.

aa. Person Class File. The taxonomy for licensed health care providers who can be reimbursed for health-related services rendered and is inclusive for all those who appear on the Centers for Medicare and Medicaid Provider Specialty listing. It reflects training, licensure, and scope of practice for that individual. Person Class associations are part of the minimum data set reported to the National Patient Care Database, which is VHA’s principal national repository of patient care data. See VHA Directive 1066, Requirement for National Provider Identifier and Taxonomy Codes.

bb. Query Form. A query form is a written communication tool sent by clinical documentation integrity or clinical coding personnel to a provider when health record documentation is unclear or conflicting.

cc. Referral. A referral is a request to evaluate and assume the responsibility for care.

dd. Resident. A resident is an appointed VA health professions trainee who makes entries in a health record. NOTE: Veterans admitted to CLC care units and MHRRTPs may also be referred to as “residents;” however, for purposes of this directive. CLC ‘residents’ are defined as “patients.”

ee. Resident Assessment Instrument Minimum Data Set. Resident Assessment Instrument (RAI) Minimum Data Set (MDS) is a standardized instrument specifically designed for nursing homes; currently RAI MDS is used in VHA’s CLC, (formerly known as Nursing Home Care Units) and Spinal Cord Injury and Disorders (SCI&D) units that are surveyed under The Joint Commission’s Long-term Care (LTC) Standards. All assessments are completed according to national guidelines and are used for treatment planning. Use of the electronic version of the RAI MDS software is required for all CLC admissions and for all admissions to SCI&D units surveyed under The Joint Commission LTC standards.

ff. Retired Health Record. A retired health record is a health record that has been inactive for 3 years or more that is stored off site at an authorized records and storage facility or archived to electronic storage medium.

gg. Retract. Is used to withdraw, call back, or indicate an item when validity or integrity is no longer in place.

Dated: November 29, 2022

hh. Shadow Records. Shadow records are defined as duplicate health records that are kept for the convenience of a department or health care provider.

ii. Templates. Templates are only available in the Graphical User Interface (GUI) version of EHR; they permit rapid entry of information for Progress Notes and Consult Requests using radio buttons, check boxes, and free-text fields. These templates are used with any appropriate note title and contain text, Text Integrated Utilities (TIU) objects, and Template Fields that can be placed in a document. Templates can also include overprinted paper health record documents.

jj. Terminal Digit Order. The Terminal Digit (TD) order is the filing system for the health record system. In this filing method, a number is divided into two-digit pairs and read in those pairs from right to left rather than left to right for filing purposes.

kk. Store and Forward. Store and Forward is the use of imaging technologies at the patient site to acquire and store clinical information (e.g., data, image, sound, video) that is then forwarded to (or retrieved by) another health care practitioner site for reading, review, and clinical evaluation. For VA purposes, a telehealth contact between a practitioner and a patient is an encounter if the specific conditions are met as outlined in Decision Support System (DSS) instructions for Telehealth. The provider’s encounter does not always occur simultaneously with the patient’s encounter.

ll. Text Integrated Utilities. TIU is a document management application. TIU documents include, but are not limited to, discharge summaries, progress notes, operative reports, and consult reports.

mm. Veteran Health Information Systems and Technology Architecture. VistA is a rich, automated environment that supports day-to-day operations at VA medical facilities. It is built on a client-server architecture, which ties together workstations and personal computers with graphical user interfaces at VA medical facilities, as well as software developed by local medical facility staff. VistA also includes links that allow commercial off-the-shelf software and products to be used with existing and future technologies. It was previously known as the Decentralized Hospital Computer Program (DHCP).

nn. Visit. The term visit is used for reporting services provided to a Veteran and patient in a 24-hour period; for example, the visit of an outpatient to one or more clinics by location within 1 calendar day at VA medical facilities.

4. RESPONSIBILITIES

a. Chief of Staff. The Chief of Staff has ultimate oversight responsibility for health record timeliness, accuracy, and completion; however, the author of the entry is responsible for completing, authenticating, and correcting any health record deficiencies within the time frame defined by the facility policy or medical staff by-laws.

Dated: November 29, 2022

b. Chief of the Clinical Service. The Chief of the clinical service, or designee, is responsible for the clinical management of health records, with each clinician and professional service contributing to the content of the patient health record.

c. Clinical Providers. Clinical providers are responsible for ensuring documentation in the health record is complete and accurate, and adequately supports services provided.

d. Chief, Health Information Management. The Chief HIM is responsible for the administrative management of health records, which includes planning, managing, advising, and directing the health information program in accordance with applicable Federal laws, facility by-laws, VHA policy, The Joint Commission standards, the Commission on Accreditation of Rehabilitation Facilities (CARF), and other regulatory and accrediting agencies. The Health Information Manager also creates and monitors systems to ensure accurate, timely, and complete health records, in accordance with VHA policy and The Joint Commission health information protocols.

5. MANAGEMENT OF HEALTH RECORDS

a. Ownership. A health record and the health information within the health record are property of VA, as specified by 5 U.S.C. 552a(a)(4) and 44 U.S.C. 3301.

b. Health Record Creation. A separate, unique health record is created and maintained for every individual assessed or treated by VA, as well as those receiving community or ancillary care at VA expense. It is not required to print and file paper documents from electronic media for active health records.

(1) Patient health records must be maintained on the following individuals:

(a) The individual admitted to any level of inpatient care (medical facility, Mental Health Residential Rehabilitation Treatment Program (MH RRTP), CLC, etc.).

(b) The applicant who is found not to be in need of care or ineligible for care.

(c) The individual who is dead on arrival (authorized or unauthorized admission).

(d) The individual who is provided with ambulatory care for humanitarian reasons.

(e) The Veteran whose State Home or non-VA medical care or treatment is provided at VA expense.

(f) The Veteran whose community nursing home care is provided at VA expense.

(g) The Veteran examined for possible exposure to herbicides (includes Agent Orange), radiation, asbestos, and environmental contaminants.

Dated: November 29, 2022

(h) Veterans undergoing Compensation and Pension (C&P) or Persian Gulf examinations.

(i) The individual placed in pre-bed care, on ambulatory care or outpatient status, or on non-VA medical care status.

(j) The non-Veteran patient who is evaluated or treated in a VA medical facility under a sharing agreement (i.e., TRICARE, Civilian Health and Medical Program of VA

(CHAMPVA)).

(k) A family member or significant other of a Veteran attending individual counseling.

(l) A Veteran who is being treated at a Community Based Outpatient Care (CBOC) under VA auspices or at a VA medical facility.

(m) Patients examined for Military Sexual Trauma (MST).

(2) The primary traits used to uniquely identify a patient within the Master Veteran Index (MVI) include, but are not limited to, the patient’s name, SSN, Date of Birth (DOB), and gender.

Secondary traits that may be used include, but are not limited to, the mother’s maiden name, address, and place of birth (city and state).

(a) The name entered into the patient’s electronic health record must be the complete legal proper name and include a full middle name when available.

(b) In the event the identity of a patient is unknown, a pseudo SSN is assigned with 1900 entered for the DOB, and the name entered as UU-UNRESPONSIVE, PATIENT.

Subsequent patient health records must be entered as UU-UNRESPONSIVE, PATIENT A, UU- UNRESPONSIVE, PATIENT B, etc. The patient is then treated as a non-Veteran, humanitarian emergency, until the patient’s identity can be established. Health records must be completed with appropriate identity data elements once the patient has been identified (see VHA Directive 1906, Data Quality Requirements for Healthcare Identity Management and Master Veteran Index (MVI) Functions, for more information regarding requirements for identity management and MVI functions).

(c) If a patient is admitted under an incorrect name, once the name correction is made in VistA, all electronic documentation must be linked to the correct patient (see paragraph 25g(1) of this Handbook) including health information in packages other than Text Integration Utilities (TIU) and CPRS (i.e., laboratory, radiology). If assistance is required in ensuring that all unique identifiers are correct at the enterprise level, the national Healthcare Identity Management

Dated: November 29, 2022

(HC IdM) Data Quality Team should be involved in the resolution process. All paper health information must also be corrected to reflect the correctly identified patient.

(d) Official name changes to the electronic health record must be coordinated with the local site’s MVI Point of Contact, Privacy Officer, and the national HC IdM Data Quality Team.

(e) Written requests for a name change, including removal of a middle name or middle initial from health records, are handled as a request for amendment of health records.

Official documentation is required for all name change requests. NOTE: The required documentation varies based on the type of modification being requested (i.e., correction, change, removal). Some requests are not granted.

(3) Health records must contain original signed documents, or electronically authenticated documents.

(4) Health Record data within the electronic health record system will not be purged from the electronic system.

c. Legibility. Legibility refers to the quality of penmanship used when recording data, including a clear, written signature, as well as content and appearance of dictated, copied, or scanned information. Paper entries must be made in black ink to ensure permanent recording.

NOTE: Handwritten entries are limited to those documents that current technologies cannot yet support.

d. Symbols, Abbreviations, and Acronyms. While there is no requirement by The Joint Commission for a list of approved symbols, abbreviations, and acronyms, if they are used in the health record, there must be an explanatory legend or standardized list available to decipher their meaning. There must be a list of unapproved symbols, abbreviations, and acronyms which must be made available to all those who make entries in the health record and to others who use health records in the course of their official duties. Symbols, abbreviations, and acronyms are not to be used when documenting final diagnoses and procedures on patients released from inpatient, ambulatory or outpatient services. When included in information provided to patients (e.g., consent forms), abbreviations and acronyms must be explained in language that the patient can understand.

e. Language. All entries must be in English and must conform to acceptable English grammar. Documents that provide information to patients (e.g., consent forms) may include Spanish translations, when appropriate, provided that both Spanish and English translations are included in the document.

f. Shadow Records. Shadow records (see Appendix A) must be limited or non-existent.

Dated: November 29, 2022

(1) To ensure compliance with The Joint Commission standard RC.01.01.01, there must be a process to track the location of all components of health records, including shadow records.

(2) Facility HIM Managers must be aware of any use of shadow records and, with the advice of the Facility Records Manager and the Medical Record Committee or equivalent, each site must determine the need to continue the use of any shadow health records and document such action in the committee minutes.

(3) Any use of shadow records must include a policy to address the privacy, security, and destruction of shadow records that may not be under the control of the HIM Manager.

g. Forms and Template Management.

(1) A local process for initiating, developing, and approving new electronic templates and overprinted paper health record documents must be established under the auspices of the health record review function.

(2) All internally generated forms and shared templates that become part of the health record must receive prior approval. Requests for new forms and templates are to be limited to those that can be developed in an electronic format.

(3) As part of the health record review function, proposed templates must be reviewed for legal, policy, regulatory compliance, and ease of use. Requests must be approved via the facility approval process prior to implementation.

(4) All components must reflect patient identifier information (full name and second unique identifier, such as Integration Control Number (ICN); when possible, the last four digits of the SSN are used instead of the full SSN), date of documentation, date of service, and facility name.

(5) VHA paper forms for specific components of the record are no longer mandated;

however, they are encouraged to be used as a guideline for developing electronic templates.

h. Health Record or Health Information Availability. A local policy and process must be established ensuring health information is always available, as needed (see paragraph 11.d. of this Handbook).

(1) For most cases where a patient is treated or seen at another VA medical facility, the Patient Data Exchange (PDX), Network Health Exchange (NHE) or Remote Data View (RDV), Remove Image View, VistA Web, or Register Once software must be used to expedite the transfer of needed health information between facilities. Scanned documents and images are only viewable through Remote Image View in VistA Imaging. Facilities must use the PDX encryption feature when transmitting data to other VHA facilities. If additional information is required, it may be copied and sent using overnight mail or secure fax machine when absolutely necessary.

Dated: November 29, 2022

(2) Previous inpatient and outpatient health records must be made available upon specific request for treatment purposes or as support for claims benefits. When there is evidence that a health record exists at another VA medical facility or, at the VA Records Center and Vault (RC&V), the record must be ordered upon specific request (see paragraph 17.b. of this Handbook).

i. Preparing Records for Litigation. Records for litigation that are unsigned, or with incomplete entries, must be presented for court exactly as they existed at the time the VA medical facility received the court order for the records. The same applies for records requested by Regional Counsel. If the VA medical facility needs to complete or sign the records in order to comply with VHA and facility policy, it needs to be done after providing the unsigned copy to the requestor. NOTE: Refer to HIM Practice Brief #4, “Guidelines for Defining a Legal Health Record,” for specific guidance on preparing a record for a Tort claim.

6. ACCESS TO HEALTH RECORDS AND HEALTH INFORMATION

a. Access to health information is controlled, based upon specific criteria, to ensure integrity, minimize the risk of compromising confidentiality, and increase reliability. Only minimal access necessary to perform official job functions must be provided to employees, by the employee’s supervisor.

b. Access to health records and health record file areas is limited to authorized personnel. Only authorized personnel can print extractions from the patient’s electronic health record or to make copies from the paper chart.

c. Active or inactive health records must be readily accessible to authorized clinical and administrative staff.

NOTE: For additional information regarding access to health records and information, specifically functional categories and associated access to health records, see VHA Handbook 1605.02, Minimum Necessary Standard for Protected Health Information.

7. DOCUMENTATION STANDARDS

a. 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 documents the care of the patient and is an important element contributing to high-quality care. The health record facilitates:

D.17 VHA HIM Health Record Documentation Program Guide Version 1.1 - 36C26225R0004 https://dvagov.sharepoint.com/:w:/r/sites/vhahealth-information-management/Practice%20Briefs%20and%20Fact%20Sheets/Legal%20Health%20Record.doc?d=w0345657b3fe146d8a54836b9ba32a60c&csf=1&web=1&e=LLkT2U https://dvagov.sharepoint.com/:w:/r/sites/vhahealth-information-management/Practice%20Briefs%20and%20Fact%20Sheets/Legal%20Health%20Record.doc?d=w0345657b3fe146d8a54836b9ba32a60c&csf=1&web=1&e=LLkT2U

Dated: November 29, 2022

(1) The ability of the medical staff member and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor the patient’s health care over time;

(2) Communication and continuity of care among VA medical staff members and other health care professionals, including Community Care providers, involved in the patient’s care;

(3) Accurate and timely claims review and payment;

(4) Appropriate utilization review and quality of care evaluations;

(5) Collection of data that may be useful for research and education; and

(6) Accurate coding of diagnosis and procedures performed.

b. The Joint Commission standards regarding documentation pertinent to care and treatment records apply to both paper and electronic records.

c. The primary medium for documentation of all patient care activities within VHA is the

EHR.

d. The supervising provider or attending medical staff member is ultimately responsible for the accuracy of the health record for each patient under the medical staff member’s care. The Chief of Staff, or designee, has oversight responsibility for health record timeliness, accuracy, and completion.

e. Opinions requiring medical judgment must be documented or authenticated only by supervising providers or VA medical staff members, and other individuals who have been granted such clinical privilege within their scope of practice.

f. VA health care providers must document according to generally accepted documentation practices for completeness and timeliness.

g. The VA Practitioner who treats the patient is responsible for ensuring the care provided is adequately documented and authenticated.

h. The health record needs to reflect accurate and clinically relevant statements;

derogatory or critical comments are prohibited. Individual employee names are not to be included in health record documentation unless the purpose is to identify practitioners for continuing care.

Dated: November 29, 2022

i. Emphasis is placed on relevant day-to-day entries. Timely, clinically pertinent entries must be made following examination and treatment as specified in VHA Program Guides, facility SOPs and guidelines.

j. Each patient event must include or provide reference to the chief complaint or reason for visit and, as appropriate:

(1) Relevant history, examination findings, and prior diagnostic test results; without any inclusion of HIPAA standard code sets which might introduce risk of incorrect values;

(2) Assessment, clinical impression, or diagnosis

(3) plan for care;

(4) Rationale for ordering diagnostic and other ancillary services;

(5) Date and legible identity of the health care professional; and

(6) Identification of appropriate risk factors.

k. The scope of documentation must be comprehensive enough to:

(1) Provide continuity of care;

(2) Be concise and complete;

(3) Reflect any treatment for service-connected condition(s), including Agent Orange, ionizing radiation, military sexual trauma (MST), or external contaminants;

(4) Support reported workload; and

(5) Bill for services.

8. TIMEFRAMES

a. Each entry in the health record must be completed (including authentication) within the timeframes delineated by regulatory and accrediting entities, facility SOP or Medical Staff Bylaws. Such information needs to include guidance on disciplinary action when timeframes are not met.

b. Late entries must be noted with the actual date the event occurred versus the date of documentation. Notation as to the reason for the delay must also be made. In the EHR, the date of entry identifies when the documentation occurred.

Dated: November 29, 2022

c. VA providers must monitor and take appropriate action on their computerized prompts for reminders, currently known as “View-Alerts.”

9. AUTHORIZED ENTRIES IN HEALTH RECORDS

a. Procedures must be established at each VA medical facility to ensure only authorized individuals document in the health record and that the author(s) and any required cosigner(s) are identified. In VistA/CPRS this would include Authorized Subscription Utility (ASU) rules.

b. ASU rules must be in concert with VA medical facility by-laws.

c. VA medical facility by-laws must be reviewed regularly and updated, if necessary, to depict who is authorized to make entries in the health record.

d. Caution must be exercised to ensure that any documentation included in the health record represents work that is appropriate within an individual’s scope; i.e., calls from patients that may include questions or comments that accompany the request for medication refills may be more appropriately documented by a nurse versus being captured by a clerk.

e. Only those individuals authorized by VA medical facility by-laws can make entries into the health record. This includes administrative documentation.

f. The VA health care provider who treats a patient is the individual responsible for documenting and authenticating the care provided. Interdisciplinary notes are used when multiple practitioners provide treatment during the same encounter.

g. All VA medical staff authorized to document in a health record must record in the EHR, except for those instances where technology is not available for electronic entry.

h. The respective VA medical staff, as defined by their scope of practice, must document every episode of clinical care.

i. Facility assignment of the responsibility to identify and assign appropriate health record access for staff and recommend standard ASU Business Rules, security keys, and menu options by role.

j. Define how record reviews will include components to ensure documentation by administrative staff is appropriate by facility SOP or guidelines.

k. Documentation within the health record must be within the author’s scope of

Dated: November 29, 2022 practice. For individuals who do not have a scope of practice, such as administrative staff, facility SOP or guidelines will define types of documentation approved for entry by administrative staff.

l. Health record entries must be completed, signed, and cosigned as necessary, transmitted, filed, or uploaded to ensure the information is available for patient care.

Health care providers are responsible for completing their respective notes within prescribed timelines for patients under their care.

m. A “Report of Contact” template can be used to document communications with patients. This practice must be reviewed by the appropriate health record committee and approved to ensure that the health record only includes information that supports the patient’s treatment. If the ROC is scanned as an administrative document, it is not visible in My HealtheVet.

10. AUTHENTICATION

a. Authentication demonstrates that the entry has not been altered. Authentication includes the time, date, signature or initials, and the professional designation of the practitioner (credentials).

b. Standardized and current electronic signature blocks for all authorized users based on the person’s class taxonomy file must be maintained at each facility. This ensures non-repudiation and appropriate billing occurs.

c. Authentication functionality must include the identity and credential or professional discipline of the author, the date signed, and the time signed, if required.

d. If the title block is used, it needs to accurately reflect the functional position of the user as defined by the service.

11. COMPLETE AND INCOMPLETE RECORDS

a. Record Completion. Patient health records must be timely, relevant, necessary, complete, and authenticated.

(1) Completeness implies that all required data is present and authenticated; all final diagnoses are recorded without use of abbreviations; and the transcription of any dictated information is completed, inserted, or uploaded into the health record and authenticated.

(2) Health record completion and delinquency SOPs must be developed and must be consistent with accreditation standards, regulatory requirements, and medical staff guidelines.

Dated: November 29, 2022

These SOPs must specify time standards for content, authentication, and completion as required by The Joint Commission or VA medical facility SOP or Medical Staff Bylaws.

(3) Describe procedures for ongoing monitoring and reporting of individual delinquent records, responsible VA health care providers, and re-occurring delinquency patterns to the appropriate staff and committees as outlined in the facility by-laws.

(4) Define when health record deficiency patterns become part of the individual’s (including residents) evaluation and placed in that clinician’s credentials file.

(5) Address whether students in teaching institutions can record in the official health record and the accuracy requirements for their entries.

(6) Define those entries in the health record that require countersignatures by supervising providers.

(7) Designate how the supervising provider records findings or pertinent observations that are not in agreement with the data already recorded; i.e., by an authenticated addendum or separate note.

(8) Ensure the presence and authentication of, at least, the following entries when appropriate:

(a) History and Physical (H&P) examinations;

(b) Operative reports;

(c) Diagnostic and therapeutic procedures;

(d) Consultations; and

(e) Discharge summaries.

(9) Ensure that the discharge summary and the operative reports are signed and co-signed, as necessary, by the supervising provider.

(10) Define when an inpatient health record becomes delinquent; however, in no case can the time period detailed in the medical staff rules and regulation exceed 30 calendar days.

NOTE: Completion of the health record as close to the date of discharge is strongly encouraged.

To determine delinquency, the average acute care health record delinquency rate needs to be noted. This includes health records delinquent for any reason. The total average is the total of all quarterly averages divided by four.

Dated: November 29, 2022

NOTE: The total average is compared to the Average Monthly Discharge (AMD) Rate. The AMD is the total number of inpatient discharges in the 12 months prior to survey divided by 12.

This number represents all inpatients (and can include other records such as observation beds, ambulatory surgery, endoscopy, cardiac catheterization, or emergency department. The records included for delinquency counts need to be included in both the numerator and denominator of the calculations.). It does not include any other type of ambulatory or outpatient encounter.

b. Declaring a Health Record “Complete for Filing.” A health record is declared “complete” for filing when all required documentation is present and authenticated by the author or co-signer.

(1) If unusual circumstances prevent proper completion by the author, such as when author relocates, dies or has an extended illness, the Chief, HIM can be given authority to declare that a record is complete for filing. In this case the incomplete health record is referred for authentication to the Chief of staff or a provider in the same specialty to the complete the record so that coding, billing, and statistical information is available.

(2) In the case of Residents, clearance in the HIM Department should be performed prior to the end of the residency period.

(a) When referred to the appropriate medical staff committee in unusual circumstances, the committee may declare an incomplete health record to be filed as complete, the portion(s) known to be incomplete, and the reason(s) normal completion could not be accomplished must be noted in the health record and this must be documented in an administrative progress note, and signed by the HIM professional, or designee.

(b) A sample statement such as “Approved for filing incomplete on (date) by medical staff committee due to (reason)” may be used to note the health record as incomplete. This statement does not legally imply that the signer is validating the contents of the document, rather is only administratively completing the health record. This statement must not be used on a routine basis to close health records due to the failure of an author to sign the documents.

(3) If unusual circumstances prevent proper completion by the author, due to unusual circumstances, the incomplete health record is referred for authentication to the Supervising Provider or Chief of staff to the complete the record so that coding, billing, and statistical information is available.

c. Authenticating Documents.

(1) To avoid completing a health record on an unfamiliar patient, a medical staff member must not authenticate entries that are not the staff member's own.

Dated: November 29, 2022

(2) A supervising provider or medical staff member may, however, summarize a course of treatment based on existing patient health record documentation, or review a summary for consistency with existing patient health record documentation, if the original supervising practitioner or medical staff member responsible for the patient's care is no longer available to do

so. In such cases, a notation must be made in the health record to the effect that the summarization (review) is being done from existing documentation in the absence of the supervising practitioner or medical staff member responsible for the patient's care and without personal knowledge of the patient.

(3) The completed summarization must be authenticated and dated by the medical staff member preparing the summary or the supervising practitioner.

NOTE: The health record is declared complete once all required documents are present and authenticated

d. Unauthenticated Documents.

(1) Unauthenticated documentation is considered “incomplete” and, in the EHR, is subject to revision and potential deletion by the author.

(2) SOPs to track and complete unauthenticated documentation must be established by each VA medical facility.

(3) Paper documents must be authenticated prior to document imaging (scanning).

Scanning is an administrative process which does not require the document author’s re-authentication.

e. Order Statuses and Signatures. VA medical facilities are responsible to address orders that are unsigned. This includes having a facility SOP or guidelines that identifies who is responsible to sign when a provider is no longer available. There is no way to administratively complete an order. The status of protocols, verbal orders, residents, and facility bylaws all help define how the VA medical facility practices the completion of orders.

12. HEALTH RECORD ALTERATIONS AND MODIFICATIONS

A local procedure must be established for correcting erroneous patient information entered electronically or on paper. To make a correction on paper, the author draws one line through the erroneous information, initials, and dates. Never use white out or otherwise obscure information to make the correction. When an alteration of a health record includes an image, the image must also be altered in the same manner to be congruent with the change in the note. It is the responsibility of the Health Information Management (HIM) professional to ensure there is a

Dated: November 29, 2022 process in place to correct erroneous health information. Refer to the HIM Erroneous Corrections Guidebook for additional details.

13. TRANSCRIPTION, DICTATION AND SPEECH RECOGNITION

a. Effective management of the clinical transcription unit documentation methods directly affects the quality and timeliness of health information found in the EHR. Management activities may include:

(1) Developing dictation or speech recognition instructions and providing education for VA health care providers in the proper techniques for effective dictation or speech recognition.

(2) Ensuring timely assignment of provider dictation or speech recognition access and verify codes.

(3) Providing on-the-spot or telephonic assistance to providers having difficulty with dictation or speech recognition.

(4) Developing and monitoring quality standards for transcribed documents that are entered (directly or via upload) into the EHR, including turnaround time from completion of dictation or speech recognition until the document is ready for electronic signature.

(5) Providing adequate, current references for both in-house and at-home transcription staff.

(6) Specifying and monitoring turnaround time, quality, and confidentiality compliance whether outside or in-house transcription services are provided.

(7) Ensuring that vendors for dictation or speech recognition and transcription equipment provide routine preventive maintenance, training, support, and software upgrades.

(8) Maintaining current knowledge of emerging dictation or speech recognition and transcription technologies.

(9) Serving as a subject-matter expert in planning and decision-making activities related to transcription, dictation, and speech recognition.

b. Entry of disclaimers regarding health record documentation via speech recognition software, transcription, or templates is not recommended. The provider's authentication of documentation denotes acceptance of the content regardless of qualifying statements.

14. ENCOUNTER FORMS

Dated: November 29, 2022

While the use of electronic encounter forms is mandatory, a diagnosis selected on an encounter form does not substitute for documenting the diagnosis in a progress note. All codes attributed to an encounter must be substantiated by the documentation in the practitioner’s note. Encounter forms need to be reviewed and updated annually to reflect changes in ICD-CM and CPT codes.

15. HEALTH RECORD DOCUMENTATION

a. Electronic Health Record. All clinical staff authorized to document in the health record must record in the EHR (VistA/CPRS or Cerner) except for those instances where technology is not available for electronic entry.