36C26318Q0376-031.pdf

Minneapolis VA Health Care System July 8, 2013

Management of Environment of Care (EC) Policy #EC-14D, PIV Card Policy

SUBJECT: Personnel Identification Verification (PIV) Card Policy

1. PURPOSE: To establish policy for the Minneapolis VA Health Care System (MVAHCS) regarding the use of identification badges, including the Personnel Identification Verification Card (PIV card), for employees, volunteers, vendors, contractors, and others who either work at or conduct business on Department of Veterans Affairs (VA), its Community Based Outpatient Clinics (CBOCs), and other off-site property (e.g., Adult Day Health Care, Community Resource and Referral Center/homeless program). For purposes of this policy, VA and CBOC properties refer to all non-residential buildings on MVAHCS campuses and grounds (parking lots, recreational/therapeutic courts, picnic areas, etc.), and other leased or program areas such as the Adult Day Health Care and the Community Resource and Referral Center.

2. POLICY: The ability to identify any person at the MVAHCS is important for maintaining overall safety and security. Appropriate PIV cards will be issued to all MVAHCS temporary/permanent employees, volunteers, students, and others as defined in this policy in accordance with VA Handbook 0735. The PIV card process will enhance the security, increase MVAHCS efficiency, reduce identity fraud, and will protect personal privacy by establishing a standard for secure and reliable forms of identification. Secure and reliable forms of identification for purposes of this policy means identification issued, and based on sound criteria for verifying an individual’s identity that is strongly resistant to identity fraud, tampering, counterfeiting, and terrorist exploitation, and which can be rapidly authenticated.

Any person who is issued a PIV card must wear such in a manner where it is displayed on an outer garment or lanyard above the waist, while on duty, on official business or conducting business at any MVAHCS Facility or VA leased space. PIV cards will be worn in addition to any other program badge if so issued.

3. RESPONSIBILITIES:

A. Primarily with the PIV card, the critical roles associated with the sponsorship, registration, and issuance are:

1) Applicant—The individual to whom a PIV card needs to be issued to.

2) PIV Sponsor—The Service Line Chief/Manager/Supervisor or designated official who substantiates the need for a PIV card to be issued to the applicant and provides sponsorship to the applicant. The PIV sponsor requests the issuance of a PIV card to the applicant.

3) PIV Registrar—The entity or person responsible for identity proofing of the applicant and who provides the level of background investigation needed and applicable dates. The PIV registrar provides the final approval for the issuance of a PIV card to the applicant.

4) PIV Issuer—The entity or person that performs final identity authorization, personalization operations, and issues the PIV card to the applicant after all identity proofing, background checks, and related approvals have been completed. The PIV issuer is also responsible for maintaining records and controls for PIV credential stock to ensure that this stock is only used to issue valid PIV cards.

5) PIV Card Issue (PCI) Manager—Responsible for the overall operation of the issuance of

PIV cards at the MVAHCS. The PCI manager is responsible for ensuring that the PCI conforms to the requirements of Homeland Security Presidential Directive 12 (HSPD-12) and Federal Information Process Standard 201 (FIPS 201). The Chief of Police is designated as Minneapolis VAHCS PCI Manager.

6) Facility Privacy Official—Oversees privacy issues at the facility within the identification process.

B. Service chiefs are responsible to ensure all employees obtain new PIV cards, and for supervising the wearing of such by all employees, vendors, trainees and affiliates. The Chief of Volunteer Services is responsible for ensuring all volunteers obtain a PIV card and the wearing of such. The ACOS for Education is responsible for ensuring all trainees and affiliates wear a picture ID. The Chief of Contracting is responsible for ensuring that all appropriate contracting personnel wear a badge, PIV card or vendor identification.

C. The PIV registrar is responsible for verifying the information provided by the sponsor, serving as approval for the issuance of a badge. Registrars are responsible for identity proofing the applicant and verifying that the appropriate level of the applicant’s background information is complete. Registrars have the responsibility to collect the applicant’s biometric information such as fingerprints and facial image.

D. The PIV issuer is responsible for verifying the applicant’s information and the signature of the sponsor and registrar, printing badges and PIV cards, and completing post issuance steps with the card applicant. Issuer must perform card lifecycle management processes that include, but not limited to: PIV card termination, PIV card re-issuance and Personal Identification Number (PIN) reset. Issuer must maintain a smart card inventory log and provide the required reports to the PIV Program Office.

E. All MVAHCS employees are responsible for the care of any PIV card issued, the wearing of such, and advising appropriate persons when such are lost, damaged or stolen.

F. Police Service is responsible for enforcing all aspects of this policy, to include the printing and issuance of PIV cards and badges, and for collecting all forms of VA identification from employees when they terminate employment. Police Service will ensure that all employees, vendors, volunteers, contactors and others comply with the intent of this policy.

4. PROCEDURES:

A. Who Must Wear VA PIV Badges. The following personnel must wear a VA PIV badge:

All Salaried Employees—Permanent, temporary/term, full-time, part-time, intermittent, consultant, and fee basis personnel.

Without Compensation (WOC) Employees—Including staff, researchers and research assistants, trainees and students.

Residents and Fellows.

Medical Students and Nursing Affiliates.

Contract Personnel.

Long Term Visitors--Any visitor of the MVAHCS who is here on official business and will be here for one week or more (e.g., audit and inspection teams, vendors). These will be PIV flash badges with photos on them.

Note: VA volunteers are addressed in Voluntary Service procedures.

B. PIV Card: An Applicant applies for a PIV card by completing electronic VA Form 0711 via the HSPD-12 PIV Portal, which contains the following sections:

1) SECTION I - Applicant Information-Completed by applicant with the assistance of the sponsor.

2) SECTION II - Sponsor Verification-Completed by sponsor.

3) SECTION III - Applicant Identity Verification-Completed by registrar.

4) SECTION IV - PIV Card Acceptance – Completed by applicant and issuer.

5) SECTION V – Issuer – Completed by issuer.

C. PIV Cards (Badge): Employees of Minneapolis VAHCS will be required to wear a means of photo identification while in a duty status. Photo identification will be in the form of a PIV card and must be prominently displayed. Vendor and contracting pass badges without an affixed photo are not considered a means of photo identification.

1) PIV cards will be issued by the Minneapolis PIV Office located in 4N-101, Building 70.

2) Employees will display PIV cards on their clothing with their name and photo clearly visible. In accordance with VA Handbook 0735, names on PIV cards will be displayed in one of the following forms:

a) Legal name as it appears on the employee's accepted identity source document, (Appendix B-Identity Documentation Criteria);

b) Full last name, first name, middle initial

3) The badge will not be decorated with pins, stickers, etc. which obscure the name and/or information of the employee. It is prohibited that the PIV card be decorated with any item.

4) The PIV card may be removed due to safety concerns when the employee is engaged in "close work” or dangerous situations.

5) Employees, volunteers, vendors, contractors, trainees and affiliates are responsible for immediately reporting lost or stolen PIV cards to Police Service and their supervisor, or service line designee. Replacement PIV cards will be provided free of charge to employees, volunteers, trainees, affiliates and vendors in the event of a name change or destruction of the PIV card through no fault of the employee, volunteer, vendor, trainee or affiliate. Replacements will be obtained at an authorized VA Facility capable of reproducing such.

6) Temporary badges or passes for official vendors will be issued by appropriate service chiefs under the guidance of Police Service and in compliance with established MVAHCS Policy #MA-08.

7) All badges, PIV cards are, and remain, the property of the Department of Veterans

Affairs.

a) PIV cards will be surrendered to Minneapolis PIV Office upon separation, and as part of the exit process. For employees of Community Based Outpatient Clinics (CBOCs), PIV cards will be surrendered to the designated official of that CBOC.

Such designated official will immediately mail, utilizing a tracking mail type system, those PIV cards to the Minneapolis PIV Office. Upon appropriate approval, employees may be allowed to retain their PIV card if transferring to another VA facility or to another VA function.

b) Residential program PIV cards will be surrendered to the Minneapolis PIV Office upon completion of program participation at the MVAHCS. Residential program participants who have not yet completed the full residential program and are expected to return to the MVAHCS on their next rotation will surrender their PIV card to their responsible residential program PIV sponsor. Subsequently the responsible residential program PIV sponsor will come to the PIV office with a memorandum from their MVAHCS residential program manager requesting temporary retention and securing of the PIV card in a specified secure temporary storage safe within the PIV office. The PIV card will be returned to the resident upon arrival of their next rotation by the responsible Residential Program PIV Sponsor. Security of surrendered PIV cards will be in compliance with standards established by the PCI manager

c) Volunteer badges and PIV cards will be surrendered to the Voluntary Service

Office upon termination of volunteer status. Voluntary Service will immediately return all badges and PIV cards to Police Service.

d) Trainees and affiliate PIV cards will be surrendered to the ACOS for Education or service line designee (e.g., manager in Mental Health, Primary Care, Pharmacy, etc.) upon completion of their rotation. The respective VA staff will immediately return all PIV cards to the MVAHCS PIV office.

e) The finding of unattended PIV cards (cards left in computers, left in common areas, etc. with no one around) should be immediately reported to an immediate supervisor. Said supervisor will immediately secure the PIV card and conduct an inquiry into the matter.

8) Contracting PIV cards will be surrendered to the appropriate service chief upon the completion of their visit. These PIV cards will be returned by the appropriate service or returned to the MVAHCS PIV office.

D. Requesting and Obtaining a PIV Card. Personnel in the above categories will obtain a PIV card during their first week of duty. A safety breakaway neck strap is available upon request. Personnel should report to the PIV Office room 4N-101 on Monday through Friday between 7:30 a.m. and 4:30 p.m.

E. Format For PIV Cards. All PIV cards will be in compliance with HSPD-12 and VA

Handbook 0735. The first and last name, or first name and middle initial will be on the photo (front) side of the badge.

F. Wearing PIV Cards. PIV cards must be worn above the waist with the picture side facing out. Exceptions (e.g., operating room personnel) must have their PIV card easily accessible.

Personnel are responsible for keeping their PIV card in good condition. PIV cards may not be defaced, including with pins or stickers. However, PIV cards may be carried in a clear protective sleeve and in the event there exist a security need to limit the first or last name but not both, opaque tape may be placed on the protective sleeve, not the PIV card. In this way when a security need arises to see the person’s name, they can remove the card from its sleeve since there would be nothing attached to the card itself.

G. Reporting Lost, Stolen, Damaged, or Found PIV Cards. Lost or stolen PIV cards will be immediately reported to the VA Police Service. Found PIV cards will be turned over to the MVAHCS PIV Office.

H. Replacing PIV Cards. PIV cards damaged through normal wear will be replaced without charge. To replace lost badges, notify the employee’s supervisor that the badge has been lost and then follow the same process in section 4B. Note: If the PIV card has been stolen, a copy of the local police report or report number (indicating the stolen PIV card has been reported to the local authorities) should accompany the application for a replacement PIV card.

I. Surrendering A PIV Card. Personnel will return or surrender their PIV card to the

MVAHCS PIV office when they clear or out-process the station, or on demand. The PIV card will then be de-activated. Note: Research investigators are responsible for ensuring that WOC researchers and research assistants return their PIV card to the MVAHCS PIV office for de-activation. If a vendor or contractor does not return their PIV card at the completion of their work, the responsible department must notify the contract officer immediately, who will then contact the VA Police Service to file a police report for the lost/stolen PIV card and notify the MVAHCS PIV office.

J. Access To The MVAHCS. A PIV card authorizes entry to the MVAHCS daily. It also permits access into the Medical Library at all times.1 Access to specially designated controlled areas will be determined by the area PSL/department director. A listing of approved personnel will be maintained and submitted by each PSL/department in electronic format to the MVAHCS PIV office. Personnel will present their PIV card at the time of entry, or upon request by VA Police. PIV cards shall be worn at all times while at the VA

MVAHCS.

1If an employee is found to have abused after hours library privileges, their PIV card will be recoded to prohibit after hours library use.

5. RESPONSBILITIES: All personnel listed in section 4A are required to comply with this policy. Failure to do so may result in disciplinary action.

6. REFERENCES: VA Directive 0735, Homeland Security Presidential Directive 12 (HSPD-

12) Program.

7. RESCISSION: Policy # EC-14C, Identification Badge System, dated March 6, 2009.

8. FOLLOW-UP RESPONSIBILITY: Chief, VA Police Service

/S/ Patrick J. Kelly, FACHE Director, Minneapolis VA Health Care System

Minneapolis VA Health Care System Environment of Care (EC) April 29, 2013 Policy #EC-28A, Operating Room Security

SUBJECT: Operating Room (OR) Security

1. PURPOSE: To ensure security of equipment, supplies and medications within the OR suite.

2. POLICY: The Operating Room will be secure at all times. Access will be restricted to authorized personnel only.

3. DEFINITIONS:

Operating Room Suite. A group of contiguous spaces related by function to the care of the intraoperative surgical patient. Included are the Operating Rooms plus all supportive areas such as the Anesthesia work room, the Clean Core, and staff lockers and lounge.

Authorized Personnel. The following are considered authorized personnel in the Operating Room suite:

Members of the patient care team including physicians, residents, medical students, nurse practitioners, physician assistants, anesthesia personnel, OR nurses and technicians, nursing assistants, and pharmacy staff.

Sterile Processing Services (SPS), Pharmacy, Biomedical, and Housekeeping staff, Radiology Technicians, AFGE officials, and Engineering and Security staff when needed to perform their assigned duties.

VA administrative staff when their duties require access to the OR such as Environment of Care rounds, Continuous Improvement initiatives, equipment inventory, etc.

Visitors, including technical consultants and vendor representatives, in accordance with VISN 23 policies for Visitors in the Operating Room and Other Areas Where Procedures are Performed.

Government and accreditation organization representatives when they are performing their regulatory responsibilities and are in the presence of an authorized VA employee.

Secure Area. An area that is locked or, when in active use, access and egress is monitored and restricted to authorized personnel.

Controlled and Non-Controlled Medications. Drugs used in anesthesia are divided into controlled (DEA Schedules II, III, and IV) and non-controlled substances.

4. PROCEDURES:

A. Operating Room Suite Access.

All doors to the Operating Room suite are locked and may be accessed by authorized personnel via an electronic employee identification badge recognition system.

To obtain authorized access to the OR, a memo from the employee’s supervisor requesting access to the OR will be submitted to the OR Nurse Manager.

The OR Nurse Manager will send an electronic email request to the VA Police/PIV office approving or denying the request to grant access to the OR suite.

Authorized personnel are prohibited from using their access to admit non-authorized personnel to the OR suite.

Non-authorized VA employees and other non-authorized individuals will call into the OR Control

Desk (ext. 1748) when they need to transact business with or be allowed into the OR.

Vendors will report to the VA Police near the outpatient entrance and be issued a day vendor badge. Vendors will call the OR control desk (ext. 1748) and access will be granted after an appointment is verified. The vendor must be supervised by an authorized VA employee.

Minneapolis VA Health Care System Environment of Care (EC) April 29, 2013 Policy #EC-28A, Operating Room Security

B. Security of Non-Controlled Medication in the Operating Room Suite.

When the OR suite is in use, non-controlled anesthesia medications may be left in or on top of unlocked anesthesia carts or machines immediately prior to, during and immediately following surgical cases in an individual Operating Room--as long as there are authorized personnel in the suite.

Since the Operating Room is secure at all times, anesthesia carts and OR medication exchange carts are not required to be locked.

C. Security of Controlled Substances in the OR Suite. Controlled substances are kept under lock and key at all times. The sole exception is for controlled substances under the direct control of the Anesthesia provider responsible for the care of the patient.

5. RESPONSIBILITIES:

The Surgery/Specialty Service Line Director is responsible for ensuring adherence to this policy.

The Operating Room Nurse Manager has day-to-day responsibility for enforcing this policy and will maintain the database of authorized employees who will be allowed access to the OR.

The VA Police are responsible for entering names of authorized employees into the security software that controls the OR doors.

6. REFERENCES: Office of Inspector General, Review of Patient Safety in the Operating Room in Veterans Health Affairs Facilities, Report No. 05-00379-91, February 28, 2007; Centers for Medicare and Medicaid Services, Conditions of Participation-Pharmaceutical Services, 42 Code of Federal Regulations Part 482, Section 482.25(b)(2)(i); American Society of Anesthesiologists Newsletter, Anesthesia Carts: New Federal Regulations Aligns With ASA Policy, Volume 71, Number 2, February 2007, pages 32-34; policy RI 15, Visitors in the Operating Room and Other Areas Where Procedures are Performed.

7. RESCISSIONS: Policy #EC-28A, Operating Room Security, dated January 21, 2009.

8. RESPONSIBILITY: OR Nurse Manager.

Judith L. Johnson-Mekota, FACHE Acting Director, Minneapolis VA Health Care System

February 10, 2013

Surveillance, Prevention, and Control of Infection (IC) Policy #IC-01F, Infection Precautions

SUBJECT: Infection Precautions Policy

1. PURPOSE: To minimize risk of transmission of infectious agents to patients and employees.

2. POLICY: Because it is often not possible to know when an individual may be infected with an infectious agent, consistent use of a barrier to reduce the chances of direct contact with potentially infected blood and body substances is the best way to avoid accidental exposure to infection.

Accordingly, Standard Precautions have been recommended by the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration for all Health Care Workers (HCWs) whose functions could bring them into contact with blood and body substances.

Therefore, “Standard Precautions” (SP) are practiced at the Minneapolis VA Health Care System (MVAHCS). Additional Transmission-based Precautions (Airborne, Droplet, Contact and Neutropenic) will be superimposed on SP when indicated.

3. PROCEDURES:

A. Standard Precautions. The effectiveness of Standard Precautions (SP) depends on vigilant compliance by each individual staff member. Standard Precautions rely on the individual to take responsibility for his or her own potential exposure.

1. Hand-Hygiene. Hand hygiene following the care of any patient is the most effective method of preventing transmission of infectious agents. (Please refer to IC-14 Hand Hygiene Policy)

2. Gloves. Gloves will be worn by HCWs for all procedures that entail contact with mucous membranes, non-intact skin, or any body substance. Body substances include blood, cerebral spinal fluid, feces, urine, sputum, pus, saliva and tears. Gloves will be worn for all vascular access procedures. Any HCW with non-intact skin will wear gloves for all patient contact.

Any HCW with exudative lesions or weeping dermatitis should be evaluated by Occupational Health prior to any patient care. Gloves will be available at each patient’s bedside (except as distinctly contraindicated by the patient’s mental status) and in each exam or procedure room.

3. Gowns & Aprons. Gowns or aprons will be worn when extensive contact with body substances is likely, to prevent soiling of HCW clothing.

4. Masks. Masks will be worn when the HCW anticipates possible splashing of body substances, to prevent contact with nasal or oral mucosa. Infection Prevention Practices for special lumbar puncture procedures are as follows: Face masks will be worn by the healthcare provider placing a catheter or injecting material into the spinal or epidural space to prevent droplet spread of oral flora during spinal procedures.

5. Eyewear. Protective eyewear will be worn by HCW in all situations in which splashing of blood or other body substances to the eyes or mucous membranes is anticipated, including all operative and invasive procedures. In the Operating Room, loops that have shields are considered protective eyewear.

6. Mouth to Mouth Resuscitation. Mouth to mouth resuscitation is not recommended. A one-way valve mask with or without an ambu bag should be used. Masks will be available in each patient room (except as distinctly contraindicated by the patient’s mental status) and each exam or procedure area. A mask and an ambu bag will be on every emergency cart.

7. Soiled Clothing. Soiled non-disposable clothing must be changed as soon as possible (including scrub suits, uniforms, gowns, etc.). Disposable items will be disposed of promptly when soiled or after use.

8. Carts. Carts will be available outside patient rooms for patients requiring a high volume of personal protective equipment supplies (referred to as isolation carts).

9. Needles & Sharps. All needles and other sharp items will be disposed of in an appropriate needle disposal container immediately after use. Needle disposal containers will be easily accessible at every patient bedside (except as distinctly contraindicated by the patient’s mental status) and in every exam and procedure room. Needles will not be recapped or broken before disposal.

10. Soiled Linen. All soiled linen will be placed in regular cloth laundry bags. Plastic heavy-duty (non-red) bags will be used for heavily soiled or moist laundry if leakage is anticipated.

11. Soiled Reusable Medical Equipment (RME). See MVAHCS policy IC 19 – Medical Device Reprocessing.

12. Lab Specimens. Laboratory specimens from all patients are handled with equal care.

Specimens must be collected in containers that will remain leak-proof in the transport system.

The outside of the specimen containers will be clean. Specimens will be placed in plastic zip lock biohazard bag prior to transport.

13. Cleaning Up Body Substances. Body substances will be cleaned up promptly by gloved personnel using the hospital-approved disinfectant. Contact Environmental Management Service for large spills.

14. Prohibitions On Labeling. Institution of SP policies will obviate the need for labeling of patient charts, specimens, rooms, or addressograph plates. Diagnoses such as HIV, hepatitis B virus, hepatitis C virus and other infectious agents will be treated like all other diagnoses.

They will be recorded in the medical record and nursing in the usual manner.

15. Trash Collection. All trash will be collected in heavy-duty plastic bags. Biohazard trash collection from all areas within the MVAHCS will be collected and placed into a secondary covered container (properly labeled as Biohazard) and transported to the hazardous waste storage room for disposal by contracted services. Reusable sharps containers are exchanged by the responsible contracting company. All remaining trash will go to the compactor.

Disposal of trash from Research Service is addressed in XXXIV Infection Control Research Manual.

16. Deceased Patients. All deceased patients will be placed in a plastic zippered body bag prior to transfer to the morgue to prevent HCW contact with any potential leakage of blood or body fluids.

17. Employee Education. All employees will be educated about the reasons for SP and specifics that pertain to their jobs before beginning work. This will include students and volunteers. A description of SP will be included in orientation materials.

18. Needlesticks & Exposure To Body Substances. If a HCW sustains a needlestick or significant mucous membrane exposure to body substances, the HCW will report to their immediate supervisor and then Occupational Health as soon as possible. If the exposure source is known, the patient will be requested (with informed consent) to submit blood for bloodborne pathogen testing.

19. Respiratory Hygiene/Cough Etiquette. Measures to minimize the transmission of respiratory pathogens via droplet or airborne routes in healthcare settings including covering the mouth and nose during coughing and sneezing, using tissues to contain respiratory secretions with prompt disposal, offering a surgical mask to persons who are coughing to decrease contamination of the surrounding environment and turning the head away from others and maintaining spatial separation when coughing. These measures are targeted to all patients with symptoms of respiratory infection and their accompanying family members/friends beginning at the point of initial encounter with the healthcare setting.

20. Safe Injection Practices. Adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications including use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication. Use of single-dose vials whenever possible is preferred.

B. Additional Precautions. Additional precautions will be necessary for some patients. These include patients with known or suspected airborne transmissible disease, those requiring Contact Precautions, and patients requiring Neutropenic Precautions (as defined in the Infection Prevention and Control Manual). These additional precautions will be identified on a color-coded “Infection Precautions” sign. Procedures for discontinuing Transmission-based Precautions may be obtained from the IPs.

C. Other Precautions. Creutzfeldt-Jacob Disease (CJD), other spongiform encephalopathies (TSE), and some emerging pathogens may require additional precautions for management. Infection Prevention (ext 4449) or after hours the Infectious Disease on call staff, should be contacted for suspected or confirmed CJD, TSE, or emerging pathogens. Infection Prevention RNs will have access to up-to-date information on these agents.

D. Private Rooms. Infection Control recommendations will take precedence over other considerations for a private room. A private room will be assigned whenever possible for the following patients (in no order or priority):

1. Patients with poor hygiene (i.e., patients who are likely to soil the environment with body substances).

2. Patients with draining infected wounds on surgery stations.

3. Patients with secretions or excretions that cannot be contained.

4. Patients who are colonized or infected with multiple resistant organisms (as determined by the

Surveillance, Prevention and Control of Infection Committee).

5. Patients with absolute granulocyte counts (neutrophils and bands) less than 500/mm3.

6. Patients with airborne transmissible diseases that will pose significant dangers to others

(Airborne or Droplet.)

Note: Recommendations for cohorting of patients in the above groups or exceptions to the above recommendations will be made after consultation with Infection Prevention and Control personnel.

4. REFERENCES: American Hospital Association Report of AIDS/HIV Infection Policy:

Ensuring a Safe Hospital Environment, Report and Recommendations of the Special Committee on AIDS/HIV Infection Policy, November 1987; Recommendations for Prevention of HIV Transmission in Health Care Settings, MMWR 1987, 36(2S):1S-17S; Recommendations for Preventing Transmission of Infection with Human L-Lymphotropic Virus Type III/Lymphadenopathy-Associated Virus During Invasive Procedures, MMWR 1986, 35:221-223;

Recommended Infection Control Practices for Dentistry, MMWR, December 19, 2003, 52(RR17),1-61; AIDS Syndrome, Occupational Health, Bureau of National Affairs, Inc., 1986, No. 100; Infection Control Manual, Section V, Employee Health and Section VI, Infection Precautions; Occupational Exposure to Bloodborne Pathogens, Final Rule, Department of Labor, OSHA, 29 CFR Part 1910.1030, December 6, 1991; Garner JS, Hospital Infection Control Practices Advisory Committee, CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007; Isolation Precautions in Hospitals, Infect Control Hosp Epidemiol 1996, 17:53-80; Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post-Exposure Prophylaxis - 2005, September 30, 2005, 54(RR09):

1-17; Management of Occupational Exposures to Hepatitis B, Hepatitis C, and HIV and

Recommendations for Postexposure Prophylaxis-Updated 2001 June 29, 2001/Vol. 50/No. RR- 11; Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force October 25, 2002/51(RR16).1-44; Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006, HICPAC;

5. RESCISSIONS: Policy #IC–01E, Infection Precautions Policy, dated April 3, 2009.

6. FOLLOW-UP RESPONSIBILITY: Surveillance, Prevention and Control of Infection

Committee (111F1).

/S/ Judith L. Johnson-Mekota, FACHE Acting Director, Minneapolis VA Health Care System

Minneapolis VA Health Care System Management of Information (IM) June 7, 2013 Policy IM-01K, Medical Records

SUBJECT: Medical Records

1. PURPOSE: The requirements for documentation of inpatient, outpatient, home and community living center care records are defined by this policy and are based, when appropriate, on standards published by VA, Joint Commission, CARF, the Center for Medicare and Medicaid Services, and other regulatory bodies.

2. POLICY: Documentation in patient records will be complete, concise, legible and accurate. To enhance access to patient data by health care providers and support personnel, electronic entry and storage of medical information will be used to the fullest extent possible. Manual or paper medical records will only be used if data cannot be entered electronically.

3. PROCEDURES:

A. Unique Identifiers. Each patient will be assigned a unique identifier (social security number) when first presenting for health care. The identifier is unique in the national VA system and is verified by submission to the national patient index.

B. Components of Medical Record. Every client receiving health care will have a medical record. All information stored in an electronic medium is considered part of the computerized medical record (except for Outlook and VistA e-mails, which are not part of the medical record). Paper forms will be part of the medical record if approved by the Medical Record Committee. In addition:

Collateral Records—Non-veterans will have a separate medical record if they are seen for humanitarian reasons, as an adjunct to patient therapy, or when collateral is seen or interviewed separately from a veteran patient.

Occupational Health Records—Medical information will be entered and stored electronically in the Computerized Patient Record System (CPRS) for all employees. Access to this information is restricted to Occupational Health providers.

Administrative Medical Record Folders—Original copies of correspondence, eligibility, fee basis and other documentation will be filed in the paper medical record or scanned into CPRS.

Original documents will be destroyed after scanning.

C. Scanning of External Source Documents (Outside Records) into CPRS. To enhance access to pertinent clinical documentation provided by non-VA health care providers without compromising patient safety or liability, scanning of external source/outside documents into CPRS will be limited as follows:

The File Room will automatically scan the following external source/outside documents: all discharge summaries; operative reports; histories and physicals; pathology reports; CT, mammogram and MRI reports; and procedural reports for endoscopies, echos and cardiac caths.

All other documents will be returned to the appropriate provider.

The appropriate provider will review any other documents that were not automatically scanned (per above) according to the following algorithm:

1. Pertinent clinical external source/outside documents will be summarized in a progress note by the provider and shredded.

2. Pertinent clinical external source/outside documents that are identified as critical to be placed in the electronic record must be signed by the provider and returned to Scanning via the ‘Scanning’ box located in the clinic area.

3. External source/outside documents returned to Scanning unsigned by the appropriate provider will be returned to the provider for shredding.

A request to amend an external source document must be referred back to the original source.

D. Entry of Information into the CPRS.

1. Shadow Records. Shadow records (an original document maintained outside the medical record) are not allowed except in the following instances:

Psychology—will keep original test results and place a report detailing the results in the medical record.

Radiation Oncology—will keep originals of their physiologic measurements and include a summary in the medical record.

Dialysis and Hematology/Oncology—will keep original records of procedures until treatment is complete and then incorporate into CPRS.

2. Authorization to Enter. Staff must be authorized to enter clinical information into CPRS. Scope of practice statements and credentials specify an individual practitioner’s authority to enter information and write orders. All entries will be in English. Transcription by appropriately trained staff is an acceptable method of entry into CPRS.

Clerical Staff—are authorized to enter patient postings. They may also write, "No Show,"

"Appointment canceled," and "Patient Contact” entries, but these must be verified by the appropriate clinical staff.

Scribes—Scribes may not be used at this facility. Medical Students cannot be used as scribes. See the Medical Student Documentation – Attachment C.

Residents, Fellows and Medical Students—Policy # MS-02 specifies entries that residents, fellows and medical students may make and which entries must be co-signed. Also see Attachment A.

Advance Practice RNs and Physician Assistants—Policies #HR-14 and #HR-16 specify documentation requirements for APRNs and PAs, respectively. Also see Attachment A.

Students in Authorized Teaching Affiliations—may make entries into the medical record, but the entry must be co-signed by a staff provider.

Patients: Patient written documentation may not be entered into the medical record.

Provider entry will summarize and assess the information appropriate to the encounter.

3. Making Corrections. If a note or imaging error is made in CPRS, the author must immediately write an addendum indicating the note has been entered in error. The author should then send a VistA email to the “g.error” mail group. This mail group will make the note non-viewable. All handwritten entries in the paper record must be made in indelible ink (no pencil). Errors will be corrected by drawing a line through the incorrect entry and initialing and dating the correction.

Whiteout or blocking-out data in the paper medical record is prohibited. Note: The Privacy Act of 1974 contains provisions for the amendment or correction of a medical record. In CPRS, the HIM manager or designee is provided a security key to access the computer-based record for amending or correcting the record.

4. Historical Notes. Progress notes used to enter patient flag or critical information will be made historical when the information is updated. For example, the original advance directive note will be made historical when a patient changes or updates their advance directive information. CPRS users must send a VISTA email to the g.error mail group to remove the posting or advance directive by changing the title to historical.

5. Abbreviations. Abbreviations used in the medical record must be in the latest edition of Stedman’s ABBREV: Abbreviations, Acronyms and Symbols or on a list approved by the

Medical Record Committee. Abbreviations are not acceptable in the final diagnoses on the discharge summary. The following abbreviations are also prohibited—in any form—upper or lower case, with or without periods. For clarity, instead write what is outlined below.

Prohibited Abbreviation For Clarity Write Lack of zero before decimal (such as .5mg) Add a zero before the decimal (such as 0.5 mg) Trailing zero after decimal (such as 1.0 mg) Whole numbers without a decimal and 0 (such as 1 mg) IU International units MS, MSO4, MgSO4 Morphine sulfate or magnesium sulfate Q.D., QD, q.d., qd Daily or q day Q.O.D., QOD, q.o.d., qod Every other day or q other day U or u Units

D. Viewing Entries Prior to Authentication. Health information directly entered into CPRS will not be viewable by anyone but the author until the entry has been authenticated. The only exception to this is discharge summaries, which may be viewed by clinical providers prior to authentication; however, they must be authenticated before being released outside the Minneapolis VA Health Care System.

E. Authentication of Entries. Every entry into the medical record (including progress notes and orders) must be authenticated by either direct or electronic signature. Authentication consists of date, time (if required), and the name, credential and title of the person making the entry. If initials are used on individual entries, a signature sheet showing initials and signature of the person doing the entry must be documented in the chart for each episode of care (i.e. admission, length of specified treatment or individual encounter). Note: For co-signature requirements for residents, see policy #MS-02. For co-signature requirements for APNs and PAs, see policies #HR-14 and #HR-16, respectively. In the event the author of a progress note or other paper or electronic entry is not able to sign the documentation, the service chief or section chief may sign the order or note. Otherwise, the documentation may be reviewed by the Medical Record Committee to determine if the entries should be filed as incomplete.

F. Signatures. There are three types of signatures in the electronic health record: (1) Signer–this is the author of a document; (2) Co-Signer–this is the attending, staff or supervising clinician; and (3) Identified Signer or Additional Signer–signature -only indicates the signer has received the information contained in the note (signature does not constitute responsibility for content).

G. Timeliness of Entries and Authentication and Delinquent Records. Attachment A details timeliness requirements for most components of the medical record. Entries should be made as soon as possible after or during the encounter. Required entries and authentication must be complete within 30 days after a discharge/encounter or the medical record will be considered delinquent.

H. Quality of Documentation. Individual providers are responsible for the quality, completeness, clinical pertinence and timeliness of their entries into the medical record. The Medical Record Committee, or designee, conducts ongoing monitoring of entries into the medical record. Review results are reported to Patient Service Line (PSL) leadership. PSL directors are responsible for submitting action plans to the Medical Record Committee that address identified documentation issues and implementing plans to achieve needed corrections. The Medical Record Committee chairperson reports quarterly results to the Executive Committee of the Medical Staff. Entries should not contain facetious, libelous or other-wise inappropriate or subjective remarks. Personal opinions or non-medical judgments shall not be expressed in the medical record, except as they pertain to the direct medical care of the patient.

I. Templates/Forms/Titles. The Medical Records Committee’s Forms Subcommittee or designee must approve all forms, templates, titles or other entry methodologies. Titles must conform to VISN and/or nationally published standards. Proliferation of note titles makes retrieval difficult and cumbersome. Contact HIMS for assistance at extension 2378 or 3373.

J. Accessibility of Patient Care Records.

Paper medical records are available upon request by clinicians. Paper records can be requested by calling the file room.

Inactive records stored in Federal Record Centers will be retrieved at the request of the clinician.

A patient, their attorney, or other representative can personally review an original patient record, provided their access is properly authorized. To prevent tampering or alteration of the original record, HIMS staff will observe the patient or representative during possession of any original medical record whether in paper, electronic or other medium.

K. Contingency Plan for Computer Downtime. PSLs have contingency plans detailing procedures to follow during computer failures. There is also a Minneapolis VA Health Care System contingency plan filed in the Emergency Incident Management Plan notebook located in each service/section/clinic/ward. For contingency plans regarding the Bar Coded Medication Administration system (BCMA), see policy #TX-19, BCMA.

L. Retention of Records. Medical information will be kept in an archival medium for 75 years after the last date seen or as specified in VA regulation. Retention and disposition requirements are listed in the VHA Records Control Schedule (RCS) 10-1.

M. Ensuring Confidentiality. Every employee with access to patient records is responsible for proper protocol in handling records—whether in paper or electronic form—and for safeguarding patient confidentiality and privacy. See the Minneapolis VA Health Care System’s privacy policy, IM-07 for more details.

N. Security of the Medical Record.

1. Releases. Medical records are the property of the Minneapolis VA Health Care System and cannot be released unless VA release of information requirements are met. Contact ROI for assistance and/or see policy IM-02, Release of Information, Specimens and Materials. Medical records also cannot be transported, accessed, downloaded or printed off-site unless an official exception has been granted. See policy IM-07, Privacy Policy and/or contact the Privacy Officer for assistance.

2. File Room. All patient-specific medical information will be kept in a dry secure area. The Medical Record File Room will remain locked and only file room staff, HIMS-designated and other employees approved by the Director, HIMS are allowed access.

3. Clinical Areas. Medical records stored in clinic areas, inpatient units or other clinical areas will be safeguarded by the continuous presence of staff or be stored in a secure area. When accessing patient information electronically, computer screens must be secured from unauthorized personnel. Paper records will be transported by VA staff or secured in envelopes, mailbags, or secured carts. All users must discontinue access to VistA before leaving a computer.

4. Employee/Volunteer Records. Paper employee or volunteer records written prior to the implementation of CPRS will be kept in locked file cabinets in the File Room.

5. Release of Original Records. The medical record is the property of the Minneapolis VA Health Care System and will not leave the premises except in accordance with federal law, or a subpoena or court order from a United States Court. Unlawful removal or destruction of medical records will cause penalties to be enforced as provided by law (18 U. S. C. 234-235).

6. Employee Access. Access to patient-specific medical information will be limited to staff members with a legitimate “need to know” to perform official duties. Staff with access to confidential medical information will receive training in maintenance, confidentiality and security of information on initial employment and annually. The same training, guidelines and penalties apply to all staff and students in the Minneapolis VA Health Care System, community based outpatient clinics, contract facilities and research areas.

7. Electronic Signature Codes. Electronic signatures will be used in computer-based records and the signature will be secured by encryption. The computer system will not provide an electronic signature to anyone including IRM staff. All VA staff authorized to use VistA are responsible for safeguarding electronic signature codes and paper or computer-generated documents to prevent unauthorized use. Electronic signature codes will be set up by every user and changed as needed.

PSLs are responsible to ensure access to VistA is secure (for those employees who require VistA) and that employees protect the security and integrity of electronic signatures and computer-generated documents. PSLs are also responsible for defining an appropriate user class for each employee and updating user class status as needed (user class defines the entry and co-signature requirements for each individual).

8. Inactive Medical Records. Inactive medical records will be stored in federal record centers subject to laws governing confidential medical information, or with local storage companies that meet contract specifications for safeguarding the physical security and confidentiality of medical information. Transport will be done by companies meeting security guidelines specified in the National Archives and Records Administration directives.

O. Documentation Guidelines for Components of the Medical Record. Every test, procedure or treatment must be ordered and interpreted by a clinician and documented in the medical record. See Attachment A for a detailed list of documentation requirements for these components of the medical record:

Advance Directives Hand Offs When Non-Primary Care Providers

Identify Clinical Issues Requiring Follow Up by Another Provider

Against Medical Advice (AMA) History and Physicals Allergy and Adverse Reaction Informed Consent Anesthesia Evaluations & Notes Medication Reconciliation Assessment (Initial) & Treatment Plans Nursing Database Assessment: Local Anesthesia Operative Progress Notes & Reports Assessment: Pre-Sedation--Deep Sedation Orders Assessment: Pre-Sedation--Moderate Sedation Patient Education Attending Notes Problem Lists Clinical Reminders Progress Notes Consultations Time Outs Discharge Summaries Verbal Orders (Other than for Medications) DNR/DNI Orders and Code Status Progress Notes

P. Special Conditions for Surgery. Except in extreme emergencies, surgery will only be performed after the following has been completed: informed consent; appropriate history, physical examination;1

1 An appropriate assessment for a focused H&P is required for any surgery or procedure that requires general, spinal, or other major regional anesthesia, or IV conscious sedation. These procedures may be performed by practitioners who are indicated laboratory and x-ray examinations; and an entry of the preoperative working diagnosis into the medical record. If a history and physical and/or nursing assessment has been obtained within 30 days prior to surgery, this report may be used in the patient’s medical record—provided any changes that have occurred in the interim period are documented at the time of the invasive procedure.

Immediately after surgery, the following will be entered into the medical record: postoperative diagnosis; description of findings, technical procedures used, and specimens removed; and the name of the primary surgeon and any assistants. Operative reports must be authenticated by the surgeon.

Q. Rules for Copying and Pasting and/or Importing Text. All clinical medical record entries should provide an accurate depiction of evaluation and treatment at a…