ATT D23 Health Info Mgmt and Health Record Documentation -Pen and Ink- Policy.pdf

HEALTH INFORMATION MANAGEMENT AND HEALTH RECORD

DOCUMENTATION

MCP 136.26

G.V. Sonny Montgomery VAMC Jackson, Mississippi 39216

Signatory Authority:

G.V. Sonny Montgomery VA Medical Center Director

Responsible Owner:

GVSMVAMC Medical Administration Service

Rescinded Document:

136.26, Health Information Management and Health Record Documentation, dated January 16, 2019

Effective Date:

November 2, 2020

Recertification Date:

November 2, 2025

1. POLICY

This medical center policy (MCP) establishes policy and procedures for G.V. (Sonny) Veterans Affairs Medical Center (GVSMVAMC) and the Community Based Outpatient Clinics (CBOCs) to ensure timely, accurate, complete, clinically pertinent, and readily accessible patient health information which will contain sufficient recorded information to serve as a basis to plan patient care, support diagnoses, warrant treatment, support education and research, and document measurable outcomes.

2. JUSTIFICATION

This policy exists due to a local policy mandate in Veterans Health Administration (VHA) Handbook 1907.01, Health Information Management and Health Records, dated March 19, 2015.

3. RESPONSIBILITIES

a. G.V. (Sonny) Montgomery VA Medical Center Director. The GVSMVAMC Director is responsible for:

(1) Ensuring adequate resources are available to maintain complete, accurate, relevant, timely, clinically pertinent and readily accessible Veteran health records.

b. G.V. (Sonny) Montgomery VA Medical Center Chief of Staff. The GVSMVAMC Chief of Staff is responsible for:

(1) Ensuring that health care providers, including service chiefs, assigned providers, and other designated members of the health care team have complete, timely appropriate and accurate documentation in the record to identify the Veteran, support the diagnosis, substantiate medical care provided, record results, Veteran’s language preference, food and medication allergies, medication reconciliation and indicate resident supervision.

August 25, 2020 MCP 136.26

c. G.V. (Sonny) Montgomery VA Medical Center Service Chiefs. The GVSMVAMC Service Chiefs are responsible for:

(1) Ensuring that confidentiality is protected; monitoring compliance of their staff regarding the security and integrity of electronic signatures and computer-generated medical documents including the completion of these documents; management and use of order sets and overprinted forms within their service in accordance with the procedures outlined in this policy memorandum; and ensuring the training and competency of staff in their respective services through appropriate mechanisms.

d. G.V. (Sonny) Montgomery VA Medical Center Healthcare Professionals. The GVSMVAMC healthcare professionals are responsible for:

(1) Completing, authenticating, and correcting any health record deficiencies within the time frame defined by the facility policy or Medical Staff Bylaws. Each is responsible for maintaining the confidentiality of health record information in accordance with federal mandates and privacy training. Authors are responsible for obtaining appropriate and adequate training in the use of the medical record prior to use, and in accordance with their job functions.

(2) Accurately compiling a concise and relevant account of the Veteran's health care and entering this into the Veteran's medical record within the timeframes established in this and other Medical Center Memorandums (MCM) and Medical Staff Bylaws. All health care providers who make entries in the Veteran's medical record are responsible for compliance with this policy.

e. G.V. (Sonny) Montgomery VA Medical Center Chief, Health Information Management (HIM). The GVSMVAMC Chief, Health Management is responsible for:

(1) The administrative management of health records, which includes planning, managing, advising and directing the health information program in accordance with applicable federal laws, facility bylaws, VHA policies, the Joint Commission standards and other regulatory and accrediting agencies. The Chief, HIMS also creates and monitors systems to ensure accurate, timely and complete health records in accordance with VHA policies and the Joint Commission health information protocols.

f. G.V. (Sonny) Montgomery VA Medical Center, Clinical Applications Coordinator. The GVSMVAMC Clinical Applications Coordinator is responsible for:

(1) Implementing electronic charting procedures and functions concurrent with policy as determined by the medical staff, and for ensuring that organization and function of the electronic medical record is commensurate with appropriate security measures and usage by clinicians. CACs will review requests for electronic signature; setup the appropriate signature title; and issue the necessary security keys. CACs are responsible for delegating appropriate access to the computerized record based on the provider’s scope of practice as defined by center policy and Authorization Subscription Utilities (ASU) rules to ensure only authorized individuals document in the health record and the author(s) required cosigners are identified and are in concert with Medical Staff Bylaws and facility policy.

(2) Facilitating the approval and creation of all locally initiated electronic progress note titles and templates.

g. G.V. (Sonny) Montgomery VA Medical Center, Medical Record Technician Health Information Technician (MRT HIT). The GVSMVAMC (MRT HIT) is responsible for:

(1) Monitoring and emailing the delinquent medical record report to the Chief of Staff, Service Chiefs, Administrative Officers and other designated staff daily. The MRT HIT is also responsible for compiling and disseminating a monthly report to the same individuals.

h. G.V. (Sonny) Montgomery VA Medical Center, Administrative Officers or designee. The GVSMVAMC Administrative Officers or designee is responsible for:Monitoring their respective services unsigned electronic notes and incomplete encounters to ensure timely completion by service providers/clinical staff.

4. OTHER PARAGRAPHS

See SOP 136.26 for procedures to maintain adequate medical record documentation and content.

5. DEFINITIONS

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

b. Amendment: An amendment is alteration of health information by modification, correction, addition, or deletion.

c. Authentication: Authentication may include a written signature, written initials, or electronic signatures.

d. Business Rules: Business rules authorize specific users or groups of users to perform specified actions on documents in particular statuses.

e. Clinical Reminders: A clinical reminder is a notification to remind clinicians of an action that is generally required for individual Veteran or Veterans in particular groups.

f. Computerized Patient Record System (CPRS): CPRS is the primary Veteran record system that stores information in Veterans Health Information Systems and Technology Architecture (VistA). CPRS supports entry of notes and orders, rule-based order checking, and results reporting.

g. Copy and Paste: Copy and paste is duplicating selected text or graphic(s) and inserting it in another location, leaving the original unchanged.

h. Delinquent Record: A delinquent record is an incomplete inpatient record that is over 30 days old that has not been completed within the timeframe specified in the facilities Medical Staff Bylaws, rules, and regulations.

i. Document Scanning: Document scanning is digitizing documents and data via imaging and/or pictorial technology.

j. Do Not Resuscitate (DNR)/Do Not Intubate (DNI): A DNR order is a written order from the staff physician that resuscitation should not be attempted if a Veteran suffers cardiac and/or respiratory arrest. A DNI order means that the Veteran does not want to have his or her life prolonged through intubation and mechanical ventilation.

k. Electronic Signature: An electronic signature is a computer data compilation of any symbol or series of symbols executed, adopted, and/or authorized by an individual to be the legally binding equivalent of the individual’s handwritten signature.

l. Electronic Signature Block: The electronic signature block is a field that prints underneath the name of the author of a document that designates the positions of the individual at a facility.

m. Electronic Viewing: For most cases where a Veteran is treated or seen at another VHA facility, Joint Legacy Viewer will be used to expedite the transfer of needed health information between facilities; however, scanned documents are not yet viewable through this technology. Facilities will use the PDX encryption feature when transmitting data to other VHA facilities. If additional information is required, it may be copied and sent via overnight mail or fax when absolutely necessary.

n. Health summary: Health summary is the compilation of components of Veteran information extracted from other VistA applications.

o. Incomplete Record: An incomplete record is an inpatient record that is less than 30 days old that is missing content, reports, and/or authentications, as defined by Medical Staff Bylaws, rules, regulations and/or facility policy.

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 provider. The legal health record is individually identifiable data, in any medium, collected and directly used in and/or documenting health care or health status.

q. 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.

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

s. Notification: Notifications are electronic messages that provide information or which prompt staff to act on a clinical event. Clinical events, such as unsigned or un-cosigned documents, critical laboratory values, or a change in orders, trigger a notification to be sent all recipients identified by the corresponding package (Laboratory, CPRS, Radiology, etc.).

t. Ownership: The health record and the health information within the health record are the property of VA, as specified in 44 U.S.C. 3301.

u. Retention of Records: Retention policy applies to both the electronic and paper records. VHA health record retention policy is 75 years; records will be retired to the Federal Record Center after 3 years of Veteran care inactivity.

v. Retract: Retract is to withdraw, call back or indicate a time when validity and/or integrity are no longer in place.

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

x. Text Integrated Utilities (TIU): TIU is a VistA document management application.

TIU documents include, but are not limited to discharge summaries, progress notes, operative reports, and consult reports.

y. Temporary Tickler Notes: A tickler or sticky note is used as a reminder by clinicians to initiate an action on a Veteran prior to an encounter or may be used by providers to record items that need to be followed-up on Veterans at a later date.

z. Types of Signatures:

aa. Signer: Author of the document. Once a document is signed, it cannot be edited; additional documentation can be added to the original document by addenda.

bb. Co-signer: Supervising practitioner. A co-signer may also be a service chief, or designee, as defined by the organization’s bylaws and/or policies.

cc. Additional signer and identified signer are synonymous and a communication tool used to alert a clinician about information pertaining to the Veteran. This functionality is designed to allow clinicians to call attention to specific documents and for the recipient to acknowledge receipt of the information. Being identified as an additional signer does not constitute validation, authentication or co-signature. Additional signer or identified signer is not acceptable for Resident Supervision compliance.

6. REFERENCES

a. VHA Handbook, 1907.01, Health Information Management and Health Records, dated March 19, 2015 http://vaww.va.gov/vhapublications/.

http://vaww.va.gov/vhapublications/

b. VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, dated January 29, 2016 http://vaww.va.gov/vhapublications/.

c. VHA Handbook 1004.01, Informed Consent for Clinical Treatment and

Procedures, dated August 14, 2009 http://vaww.va.gov/vhapublications/.

d. VHA Directive 1036, Standards for Observation in VA Medical Facilities, dated

January 13, 2020 http://vaww.va.gov/vhapublications/.

e. Medical Center Policy B-136-22, Approved and Unapproved Abbreviations and

Symbols for Medical Records, dated January 5, 2017 https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?vie wpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx.

f. Medical Center Policy, F-118-25, Restraint and/or Seclusion of Veterans, dated

January 31, 2017

g. Medical Center Policy, F-118-49, Patient Assessment and Treatment Planning (Interdisciplinary), dated May 22, 2017

h. Medical Center Policy, F-11-99, Life Sustaining Treatment Decisions: Eliciting, Documenting and Honoring Patients’ Values, Goal, and Preferences, dated, July 5,

i. Medical Center Policy, F-122-35, Medical Center Discharge Planning Program, dated, April 5, 2018

j. Medical Center Policy, D-111-19, Home Based Primary Care (HBPC) program Policy, dated January 3, 2019

k. Medical Center Policy, B-136-42, Patient Death, Death Certificates, Disposition of Remains, and Date of Death Notices, dated December 7, 2016 http://vaww.va.gov/vhapublications/ https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx

l. Medical Center Policy, F-125-20, Informed Consents for Clinical Treatment and Procedures, dated January 9, 2018 https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?vie wpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx.

m. SOP 136.26, Procedures to Maintain Adequate Medical Record Documentation and Content, dated August 25, 2020

7. RESCISSION

MCP 136.26, HEALTH INFORMATION MANAGEMENT AND HEALTH RECORD

DOCUMENTATION, dated January 16, 2019, is rescinded.

8. REVIEW

This MCP must be reviewed at minimum at recertification and including when there are changes to the governing document, VHA Handbook 1907.01.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of August 2025. This MCP will continue to serve as local policy until it is recertified or rescinded.

In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

/s/

David M. Walker, MD, MBA, DFAPA G.V. (Sonny)VA Medical Center Director Date Approved: November 2, 2020

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

DISTRIBUTION: Emailed to the All Employee G.V. (Sonny) Medical Center Email Distribution List on (November 4, 2020). MCPs are available at: GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda wpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx

NOTE: This is an internal VA Web site that is not available to the public.