Attachment 04 - SDVAMS MCM 11-22 ELECTRONIC ENTRY OF MEDICAL RECORD INFORMATION.pdf

VA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 11-22

SAN DIEGO, CA June 30, 2020

ELECTRONIC ENTRY OF MEDICAL RECORD INFORMATION

1. PURPOSE: To establish policy and procedures to maintain complete, accurate, relevant and timely medical records, which contain sufficient information to serve as the basis for planning and documenting patient care, support of the diagnoses and warrant the treatment and outcomes, and provide for continuity in the evaluation of the patient’s care.

2. POLICY:

a. All entries into the medical record, whether handwritten or electronic, are subject to the same medical and legal requirements. All entries in the medical record (electronic or hard copy) will be completed and signed in a timely fashion. Records entered in the medical record electronically (using the current Electronic Health Record (EHR) progress note functionality or similar mechanism) should be signed when they are completed. Documents that are dictated and transcribed into the record should be signed as soon as they are uploaded into the system (Please refer to Section 5. a, Unsigned Entries).

b. Providers documenting in the EHR must avoid indiscriminately copying and pasting another provider’s progress note, discharge summary, electronic mail communication and redundant information provided in other parts of the EHR. The electronic functionality of the EHR allows importation of text and objects by copying and pasting, however this function should be used with caution and only in limited circumstances. (Please refer to Section 5. a, Unsigned Entries).

c. Unnecessary duplication of patient information may result in medical and/or legal problems. Authors are liable for the content of copied items within the notes they authenticate. Indiscriminate use of copying and pasting lengthens the note, adds information that is unnecessary, slows computer retrieval time, increases space needs for duplicate information, hinders location of information pertinent to a specific date of service., and may increase liability.

VA San Diego Healthcare System stores and retains the electronic and paper medical records including imaged documents for 75 years after the last episode of care,. The retention and disposition requirements for the electronic health record will be incorporated into the Veteran Health Administration (VHA) Records Control Schedule (RCS) 10-1, which is the main authority for the retention and disposition of VHA records

3. DEFINITIONS:

a. Addendum: An addendum to a patient note or summary is made when a clinician deems it is important to clarify information recorded in the original document or to add to the original document.

b. Administrative Correction: An administrative correction is remedial action by administrative personnel with the authority to correct health information previously captured by, or in, error. Administrative corrections include factual and transient data entered in error or inadvertently omitted.

c. Amendment: Amendment is the alteration of health information by modification, correction, addition or deletion at the request of the patient or Veteran.

d. Delete: Only unsigned documents may be deleted to remove the date, time, title, author, and content are erased from the system.

e. EHR: Electronic Health Record

f. Erroneous Entry: An erroneous entry is incorrect data within the content of a note or is information entered on a wrong patient document.

g. Reassign: This option is used when the correct data is entered on the wrong patient.

h. Retract: Retract is to withdraw, call back, or indicate an item when validity or integrity is no longer in place.

i. TIU: Text Integration Utilities: The portion of the electronic medical record that supports and controls clinical document creation.

j. TIU Business Rules: Business rules authorize specific users or groups of users to perform specific actions on electronic documents. Such rules include but are not limited to entering, editing, signing, or viewing notes

k. The Medical Record Committee (MRC): The MRC is charged by the Medical Staff through the Medical Executive Council with oversight over the content and quality of the medical record.

l. Tickler note: A tickler note is used as a reminder by clinicians to initiate an action on a patient prior to an encounter.

4. RESPONSIBILITIES:

a. The Medical Record Committee (MRC):

1) Responsible for coordination and oversight of Business Rules pertaining to documentation within the EHR and providing a summary of those rules on a regular basis to the Medical Executive Council (MEC) for approval. Under certain circumstances, the Chief of HIMS, co-Chair/MRC, can tentatively approve Business Rule changes necessary for clinical care. Any such change will be documented and reported to the MRC and MEC.

2) The MRC through the Ongoing Medical Record Review function monitors providers and the quality of their documentation. This review function will include the use of copying and pasting, and findings will be reported to the appropriate Service Chief, Medical Record Committee and the Medical Executive Council for action.

b. The MRC Forms Sub-Committee:

Is responsible for assuring template and boilerplate content is consistent with MRC guidance and that the proposed template is not a duplicate of some other existing document and meets facility-wide policy.

c. Chief, HIM or designee:

1) Is responsible for assuring that clinical providers are informed about the existence of any incomplete and/or delinquent electronic entries in the medical record for which they are responsible. Delinquencies, as noted in this policy, are also communicated to Service Chiefs, Deputy Chief of Staff, and Chief of Staff (COS).

2) Auditing of retractions/deletions and reporting to the MRC quarterly.

d. The Nursing Patient Care Council:

Is responsible for assuring any template and boilerplate content is consistent with MRC guidance and the approval of them, before they are submitted to the MRC for review and approval.

e. The Consult Committee:

Will review all incoming consult service requests and modifications to existing consult services.

f. The Clinical Application Coordination Team:

Responsible for building approved titles, templates, and boilerplates.

g. All Service Chiefs:

Are responsible for educating staff on the content of this policy and taking corrective action when staff abuse the copying and pasting function.

h. Compliance Officer:

Is responsible for monitoring compliance of documentation as appropriate to support the revenue cycle. Discrepancies found affecting billing process are to be referred to the Clinical Service Chiefs and Chief of Staff for corrective action.

i. Health care providers:

1) Are responsible for completing their respective notes for patients under their care. These providers are liable for the content of copied items within the notes they authenticate. As part of the health record review function, use of copy and paste functionality will be monitored as part of the Ongoing Medical Record Review Process, and where violations occur, findings will be reported to appropriate Service Chiefs.

2) Healthcare providers are responsible for the completion of documents created by students or house-staff assigned to their supervision.

Licensed, credentialed members of the medical staff are responsible for documenting the required components of a complete medical record for each patient under his or her care.

3) Failure to comply with these standards may be deemed a violation of the Privacy Act requirement (5 U.S.C. Section 552a(e)(5); orb.

Standards of Ethical Conduct for Employees of the Executive Branch (5 CFR Part 2635). Disciplinary action may be taken if violations of these standards are validated per VA Directive 5021. Violations may include:

a) Charge 05 - Careless or negligent workmanship resulting in waste or delay.

b) Charge 11 - Failure to safeguard confidential information

c) Charge 12 - Deliberate failure or unreasonable delay in carrying out instructions.

d) Charge 25 - Falsifying official agency records.

4) Services and Programs support the continuing development and improvement of electronic patient information. Service Chiefs or their designees will be responsible for ensuring that all employees in their service complete electronic entries in a timely fashion.

5) When the responsible staff is unavailable permanently or protractedly for other reasons, those medical records for which s/he is responsible will be reviewed by the Medical Record Committee, and if applicable forwarded to the Service Chief for possible administrative action. If the Service Chief is unable to complete the record, it will be forwarded to the Medical Executive Council, through the Service Chief, for completion. In this case, the following statement will be used to administratively complete the record: “This record is being closed administratively.”

5. PROCEDURES:

a. Unsigned Entries:

1) A warning to the author and expected signers/cosigners will be automatically generated by the VistA software system every time a document is closed without a signature.

2) Employees with unsigned medical record entries for more than two (2) calendar days will be notified by a system-generated view alert message.

3) Employees with entries left unsigned for more than fifteen working days will be reported to the appropriate Service Chief for initial action.

4) Employees with entries left unsigned for more than thirty working days will be reported to the Chief of Staff.

5) A monthly summary report of delinquencies by Provider will be provided to the Chief of Staff

6) Failure to correct incomplete documents may result in curtailing of clinical activities until the document is completed and may result in action against privileges or removal.

7) Temporary Tickler Notes do not count as an unsigned note. The purpose of this note is so that a provider can put a “reminder” in the chart.

a) These temporary tickler notes cannot be signed or co-signed

b) Should pertain only to the patient the note is assigned to

c) May be used as a reminder to review lab results, to take future action at a future date, to prompt for chart review, etc.

d) Should be deleted after its purpose has been accomplished.

e) If the temporary tickler note is not deleted after 180 days, HIM staff will remove without prior notification.

b. Timeframes:

1) Each entry in the EHR must be completed (including authentication) within the timeframes delineated by VASDHS Medical Staff Rules and Regulations.

2) 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 actually occurred.

3) Providers and practitioners must monitor and take appropriate action on their computerized prompts for signature, known as “View Alerts”.

c. Basic Documentation Requirements:

1) It is preferable to refer to other documentation in the EHR (e.g. lab results or other notes) that was reviewed rather than repeating or inserting the information into the note.

2) Clinical, ethical, financial, and legal problems may result when text is copied in a manner that implies the author or someone else obtained historical information, performed an exam, and/or documented a plan of care when the author or someone else did not personally collect the information at the time the visit is documented.

3) Documentation should not be a mirror image of previous notes.

Appropriate use of templates can reduce time spent documenting while providing pertinent information. If templates are used, the wording should be changed to reflect the care provided for the episode of care.

4) Repeating information does not provide any advantage, but instead makes reading the charts more difficult and time consuming; copied portions of notes and other data is overwhelming to the reader and dwarfs the remaining information within the note.

5) Never copy a signature block into another note.

6) Never copy data or information that identifies a health care provider as involved in care that the health care provider is not involved in.

7) Do not copy entire laboratory findings, radiology reports, and other information in the record verbatim into a note when it is not specifically addressed or clearly pertinent to the care provided.

8) Do not re-enter previously recorded data, unless specifically required for the assessment of a specific patient problem.

9) Use the functionality of importing data objects into progress notes and other documents judiciously.

10) Any imported object, dialog, etc., if used, must be reviewed and corrected at the source as well as in the document if there is any inaccuracy, and it must be pertinent to the patient assessment

d. Erroneous Documentation Removal:

1) Documentation can be edited prior to authentication with an electronic signature. After a document is signed, all corrections need to be done through Privacy Act Officer or designee.

2) Clinicians that have made an error in the EHR should immediately contact Health Information Management. (see Attachment C)

3) Auditing of erroneous documentation removal will be performed on a quarterly basis using a random sample methodology and reported to the MRC. Trends will be reported to the Service Chiefs and an action plan may be required.

e. General:

1) Service level template requests require the approval of the Service Chief using the template (the final format may be finalized between the requesting service designee and Clinical Informatics).

2) EHR title requests require the approval of the Service Chief, and Forms committee. (see Attachment A).

3) Requests for new Consult Services require the approval of the Service Chief and Chief of Staff and then routed to the Consult Team for prior approval before submission to the MRC.

4) Hospital-wide templates and/or boilerplates require the approval of the Service Chief, Form committee, and the Medical Record Committee.

These are documents that would be utilized by more than one Service, e.g., Hospital-wide H&P, Discharge Summaries, Consent Progress Note, etc. If the templates and/or boilerplates involves or affects Nursing Services, Nursing Practice Council approval is required. (see Attachment A).

5) Requests for new paper forms should be limited to those that cannot be supported by the EHR and must be forwarded to the Forms committee.

Forms submitted for consideration must have the concurrence or approval of a Service Chief. The Chair, MRC, Chief/HIM, and Chief/Support Services are responsible for approving and monitoring paper medical record forms and format. A list of forms will be provided to and reviewed by the MRC for information purposes (see Attachment A).

6) Media (e.g., CD’s. digital images, or other forms of digital information) that is part of the medical record is subject to the Privacy Act, and all other confidentiality regulations. The imaged documents are under the same provisions, and the approval process will occur at the Forms Committee. A list of requests will be provided to and reviewed by the MRC for information purposes (see Attachment B).

7) The Privacy Act of 1974 contains provisions for the amendment or correction of a medical record. To comply with this requirement in the EHR, the Privacy Act Officer or designee will be provided a security key to access the computer-based record to amending and correcting the record.

6. REFERENCES:

a. VASDHS Medical Staff Rules and Regulations

b. VHA Handbook 1907.01

c. MCM 136-33 Document Scanning Policy (Vista Imaging).

7. REVIEW DATE: June 2023.

8. FOLLOW-UP RESPONSIBILITY: Chief, Health Information (136SV).

9. RESCISSION: MCM 11-22 Electronic Entry of Medical Record Information dated 21 June, 2017.

10. DATE APPROVED BY MEC: August 19, 2020.

8/24/2020

X Kathleen Kim

Kathleen Kim, MD, MPH

Chief of Staff

Signed by: Kathleen M Kim 129269 8/24/2020

X Robert M. Smith, MD

Director

Signed by: Robert M Smith 134261 Attachment A- New Template and Boilerplate Electronic Request Attachment B- Request for Capture of Outside Records, Attachment C- Note Removal Request Distribution: SharePoint

Attachments June 30, 2020

Attachment A

New Template and Boilerplate Electronic Request

Templates, Boilerplates Electronic Request Form.doc

Attachment B

Request for Capture of Outside Records

Request to scan Non

Va documents.docx

Attachment C Note Removal Request

Note Removal

Request - SD Instructions.pdf