D.10 MCM 136-14 MEDICAL RECORDS 36C24423R0132.pdf

VA MEDICAL CENTER 595 MEDICAL CENTER MEMORANDUM 136-14

Lebanon, PA 17042 September 22, 2019

MEDICAL RECORDS

1. PURPOSE: To establish policy and procedures for the initiation, documentation, use, completion, and maintenance of medical records within the Computerized Patient Record System (CPRS).

2. POLICY: The medical center will maintain the following standards related to the maintenance of medical records and the medical record function within the facility.

a. Medical records will be complete, accurate, timely, clinically pertinent, readily accessible, and permit prompt retrieval of information.

b. The medical record will contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document results of treatment and service, and promote continuity of care among providers.

c. Medical records shall be confidential, secure, current, authenticated, legible, and complete.

d. All patient-identifiable waste paper must be placed in designated locked containers for shredding.

3. PROCEDURES: An incomplete health record is defined as any inpatient, long term care, or outpatient record that lacks signature, cosignature, dictation, and/or completion of required documentation.

a. Entries must be clear, concise, and legible. Legibility refers to the content and appearance of dictated, copied, and/or scanned information. Late entries must be noted with the date the event occurred, not the date of documentation.

b. The use of symbols and abbreviations should be kept to a minimum and are not to be used in the patient health record when recording final diagnoses and procedures on patients released from inpatient or outpatient services. Special note should be taken to the list of prohibited abbreviations, which can be viewed in CPRS under Tools on the menu bar.

c. The primary medium for documentation of all patient care activities within VHA is CPRS. Patient health records will be complete and include authenticated documents relating to:

MCM 136-14, 9-22-19

(1) The chief complaint;

(2) Medical history including details of present illness or injury;

(3) Assessment, clinical impression, diagnosis for care, and identification of appropriate risk factors;

(4) Observations, including results of therapy;

(5) Diagnostic and therapeutic orders;

(6) Reports of procedures, consultations, performed tests including results and informed consent (if applicable);

(7) Progress notes; and

(8) Discharge Summary.

d. Documentation is to be relevant to the patient care and treatment. The patient health record must reflect honest and candid statements; however, derogatory or critical comments are prohibited. Opinions requiring medical judgement must be documented or authenticated only by supervising practitioners, medical staff members, or other individuals who have been granted such clinical privileges within their scope of practice.

Individual employee names are not to be included in the health record unless the purpose is to identify practitioners for continuing care. The scope of documentation must be comprehensive enough to:

(1) Provide continuity of care;

(2) Demonstrate adequate supervision of residents and other trainees;

(3) Be concise and complete;

(4) Reflect any treatment for Service Connected (SC) condition(s);

(5) Support reported workload; and

(6) Bill for services.

e. Only health care personnel who are directly participating in the patient’s treatment are to make entries into the health record. Medical Staff Bylaws further define who is authorized to make entries in the health record. Administrative personnel are authorized to make entries into the health record for the purpose of supporting patient care activities, such as non-VA care coordination.

f. All documentation must be recorded and authenticated immediately after the care event or the observation has taken place. The Joint Commission standards regarding documentation pertinent to care and treatment records apply to electronic records. All documentation specific timeframes, content, and supervision guidelines are specified in the Medical Staff Bylaws, VHA Handbook 1907.01 (Health Information Management and Health Records), and local policy.

(1) The practitioner who treats the patient is responsible for documenting and authenticating the care provided.

(2) Health care practitioners must document according to generally-accepted documentation practices.

(3) Authentication includes the time, date, signature, and the credentials of the practitioner.

(4) Unauthenticated documentation is considered incomplete and is subject to revision and potential deletion by the author. Therefore, practitioners should be aware that there is a risk associated with clinical decision making based on data that may be changed or deleted prior to authentication.

(5) Medical staff members will only be required to authenticate their own entries or those made by staff they supervise in the care of a patient. No entries of unfamiliar patients will be authenticated in order to facilitate a complete record.

(6) A supervising practitioner or medical staff member may summarize a course of treatment based on existing health record documentation, or review a summary for consistency with existing health record documentation, if the original supervising practitioner or medical staff member is no longer available to do so. In such cases, a notation must be made in the health record stating 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.

(7) Clinical practitioners must monitor and take appropriate action on their computerized prompts for signature or cosignature, currently known as “view alerts.”

(8) The Evaluation and Management guidelines used by medical coding staff for bill validation, medical coding and the education of providers followed are the 1995 version.

The exception to the use of these guidelines is for the coding of encounters for the following clinical disciplines: Neurology, Ophthalmology, and Rehabilitation Medicine, which utilize the 1997 guidelines.

g. Inpatient records will be completed within 30 days following the release of the patient from inpatient care. In addition to the items listed in 4 (c), all inpatient documentation must contain, at a minimum:

(1) History and physical (H&P) examination must be signed in electronic record within 24 hours of admission (72 hours for a Community Living Center (CLC), 7 days for the Domiciliary). A medical H&P that has been performed within 30 days before admission requires the provider to complete and document an updated examination of the patient within 24 hours of admission, but prior to surgery or a procedure requiring anesthesia services;

(2) A discharge plan, including condition on discharge;

(3) Discharge Summaries must be authenticated and routinely available in CPRS within 24 hours, but must be completed with 72 hours; and

(4) Operative procedure reports must be completed immediately following the surgery, not to exceed the same calendar day.

h. Outpatient health record documentation requirements will apply the same quality and documentation standards as inpatient health records when applicable. The outpatient documentation and outpatient encounter form should be completed the same day as the appointment and will be considered delinquent after 7 days from the appointment. In addition to the items listed in 4 (c), all outpatient records must contain at a minimum:

(1) A progress note for each encounter;

(2) Relevant history of illness or injury and physical finding, including vital signs;

(3) Patient disposition and instruction for follow-up care

(4) Immunization status, as appropriate;

(5) Allergies;

(6) Referrals and communications to other providers;

(7) List of significant past and current diagnoses, conditions, procedures, drug allergies; and

(8) Medication reconciliation.

i. Health Information Management Service (HIMS) will report incomplete records that exceed the 30-day completion requirement to the Medical Records Committee (MRC) for appropriate follow-up and/or action.

4. RESPONSIBILITIES:

a. The Director is ultimately responsible for the implementation and maintenance of an effective Health Information Management System.

b. Chief of Staff, or designee:

(1) Ensures Clinical Service Chiefs hold their providers responsible for completing health records in a timely manner according to this policy and within timeframes outlined in the Medical Staff Bylaws.

(2) Ensures Clinical Service Chiefs take appropriate action when providers are non-compliant with this policy.

c. Health Information Management Service (HIMS): Responsible for transcribing dictations by providers and scanning documents from outside sources into Veterans Health Information Systems and Technology Architecture (VistA) Imaging.

d. Associate Chiefs of Staff (ACOSs):

(1) Ensure physicians, advance practice professionals, residents, and other associated health professionals are aware of the procedure for timely completion of health records.

(2) Ensure providers take appropriate action to rectify documents.

(3) Ensure that any provider who is “clearing station” has completed their health records. If such a provider is found to have incomplete health records, the Service Chief will coordinate completion of the health records with the provider.

e. Attending Medical Staff:

(1) Completes, authenticates, and corrects any health record deficiencies within the timeframe defined by the facility policies and Medical Staff Bylaws.

(2) Cosigns any entries made by residents or non-physicians, (e.g., advance practice professionals) that require countersigning by supervisory or attending medical staff as outlined in the Medical Staff Bylaws.

f. All health care providers: Are responsible for completing medical records in a timely manner to ensure availability for continuity of care, release of information, and reimbursement purposes.

g. Privacy/Freedom of Information Act (FOIA) Officer or Alternate: The only designee authorized to amend a patient’s record after an official request for such an amendment has been received from the patient and the process for approval/denial of the amendment has been completed as outlined in Veterans Health Administration (VHA) Directive 1605.01, Privacy and Release of Information.

5. REFERENCES:

VHA Directive 1605.01, Privacy and Release of Information VHA Handbook 1907.01, Health Information Management and Health Records Joint Commission Accreditation Manuals Current Medical Staff Bylaws, Rules and Regulations Current MCM 112-02, Management of Information Policy Current MCM 136-06, Discharge Summaries Current MCM 136-08, Medical Records Committee Current MCM 100-04, Privacy Policy Current MCM 136-18, Release of Medical Information Current MCM 00-14, Restraints and Seclusion Current MCM 20-06, Informed Consent for Clinical Treatments and Procedures Current MCM 20-17, Assessment of Patients Current MCM 20-20, Consultation Procedures

6. KEY WORDS: Records, documentation, timely, incomplete.

7. AUTHOR: Chief, Health Information Management Service

8. RESCISSION: MCM 136-14, 9-22-16, same subject

9. REISSUE DATE: September 2022

Robert W. Callahan, Jr.

Director