D.13 36C26126R0014 PS-BDMS-23_Medical Record Documentation Medication Reconciliation.pdf

VA Northern California Health Care System Policy Statement BDMS-23 February 5, 2019

MEDICAL RECORD DOCUMENTATION

1. PURPOSE:

To establish policy, define responsibility, and outline procedures for documentation of health records in order to support quality of care through the complete and accurate documentation of health information for each patient and to ensure compliance with applicable legal, regulatory, and accrediting agency mandates. Health record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The health record documents the care of the patient and is an important element contributing to high quality care and supports the revenue generation process.

2. POLICY:

VA Northern California Health Care System (VANCHCS) health care providers shall keep thorough health records that document all significant information to ensure that patients receive proper care. The health record documents the care of the patient and is an essential element contributing to high-quality care. All health record documentation will record pertinent facts, findings, and observations about an individual's health history and condition including past and present illnesses, examinations, tests, treatments, and outcomes. Each entry shall be legible, accurate, timely, complete, objective, and cover all required aspects of patient care. Electronic documentation is used for communicating patient information between health care providers to facilitate treatment, for billing purposes, for preliminary assessment of potential risk management concerns, and for protecting the facility against charges of malpractice as allowed by Federal law. VANCHCS endeavors to engage in documentation practices that conform to the Centers for Medicare and Medicaid Services (CMS) guidelines.

a. Standards:

(1) The most current Joint Commission standards regarding documentation pertinent to care and treatment records apply to both paper and electronic records.

(2) The primary medium for documentation for all patient care activities within Veteran’s Health Administration (VHA) is the Computerized Patient Record System (CPRS).

(3) The Attending Physician is ultimately responsible for the accuracy of the health record for all episodes of care occurring under the physician’s care. The Chief of Staff or designee (equivalent), has oversight responsibility for health record timeliness, accuracy, and completion. It is the policy of VANCHCS that active participation in and supervision of the patient’s care, by the responsible attending physician, be fully documented.

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

(5) Health care practitioners must document according to regulatory standards and generally accepted documentation practices for completeness and timeliness.

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(6) Health care practitioners involved with the patient’s care must enter documentation of each event of a patient’s care into the health record.

Is in not appropriate to document care or treatment carried out by other providers.

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

b. Scope of Documentation:

(1) All staff members who, by virtue of their position description, functional statement, statement of work, affiliation agreement, sharing agreement, or scope of practice are authorized to document care in the health record.

(2) The health record must reflect accurate and clinically relevant statements; derogatory or critical comments are prohibited. Individual employee names are not to be included in health record documentation unless the purpose is to identify practitioners for continuing care.

(3) Emphasis is placed on relevant day-to-day entries. Timely entries must be made on appropriate documents following examination and treatment as specified in Policy Statement B&DMS- 6, Deficient Medical Records, and in accordance with Medical Staff By-laws, Rules and Regulations, and Joint Commission guidelines.

(4) Each patient event must include or provide reference to: the chief complaint and/or reason for visit and, as appropriate, relevant history, examination findings, and prior diagnostic test results;

assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the health care professional; and identification of appropriate risk factors.

(5) The scope of documentation must be comprehensive enough to: provide continuity of care;

be concise and complete; reflect any treatment for service-connected condition(s), including Agent Orange, ionizing radiation, military sexual trauma or external contaminants; support reported workload;

and bill for services.

c. Timeframes:

(1) All medical record documentation should be completed, including authentication, as close to the point of care as possible.

(2) All inpatient health records will be considered delinquent if not completed within 30 days following discharge.

(3) All outpatient encounters should have supporting documentation completed immediately following the encounter when practical, or within 7 days following date of service. The health record will be considered incomplete if not completed within 30 days following the patient encounter.

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(4) Late entries must be noted with the actual date the event occurred versus the date of documentation. NOTE: Notation as to the reason for the delay is also recommended. In CPRS, the date of entry identifies when the documentation actually occurred.

(5) Physicians and other caregivers must monitor and take appropriate action on their computerized prompts for signature, currently known as “View-Alerts.”

d. Resident Supervision: The patient record must document adequate supervision of residents and other health professions trainees in the care of patients according to the most current VHA policy (see VHA Handbook 1400.1, for additional information, and Handbook 1400.04, Supervision of Associated Health Trainees, for the supervision requirements of all other health professions).

e. Copy and Paste (Cloned Notes):

(1) The electronic functions that allow importing of text from other sources by copy and paste or use of objects are powerful tools; however, this functionality must be used with extreme caution and according to VHA. Clinical, 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. NOTE: Multidisciplinary referrals such as VHA organ transplant referral are not subject to this limitation as they are created for the sole purpose of expeditious clinical review, not to document clinical progress.

(2) Copying information from other documents in VistA (or CPRS), or otherwise importing information such as objects (i.e., medication or problem lists) is unnecessary duplication of information that does not assist those reading the record. Problem list may reflect the list at the time of the note/visit, but problem lists change over time. 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.

(3) It may be appropriate to copy information from one part of the record to a current progress note ONLY if it is critical that information be repeated in the current note and has a direct impact on care rendered during that encounter. If this determination is made, the following are rules for importing or copying text:

(a) Never copy the signature block of a complete note into a new note.

(b) Never copy data or information that identifies a healthcare provider as involved in care that the healthcare provider is not involved in.

(c) Do not copy entire laboratory findings, radiology reports and other information in the record verbatim into progress notes, consults or discharge summaries when it is not specifically addressed or clearly pertinent to the care provided. A liability issue may occur when abnormal test results (i.e. x-rays, etc.) are contained within the body of a note, but not addressed in that note. Data copied into the record needs to be specific and pertinent to the care provided.

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

(4) The authors are liable for the content of copied items within the notes they authenticate.

Each progress note should be a succinct recapitulation of a unique episode of care. Validity of an exam may be questioned if each exam contains exactly the same wording in exactly the same sequence as a previous note.

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

(b) As part of the health record review function, use of the copy and paste functionality must be monitored, and where violations occur, findings must be reported to the Medical Records Committee. NOTE: Criminal charges may be filed when in violation of Federal law. Failure to comply with these standards may be deemed a violation of the:

(1) Privacy Act requirement (5 U.S.C. Section 552a(e)(5)); or

(2) Standards of Ethical Conduct for Employees of the Executive Branch (Title 5 Code of Federal Regulations (CFR) Part 2635).

(c) Disciplinary actions may be taken if violations of these standards are validated according to VA Directive 5021, Employee/Management Relations. Violations are:

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

(2) Charge 11 - Failure to safeguard confidential information.

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

(4) Charge 25 - Falsifying official agency records.

3. DEFINITIONS:

Refer to VHA Handbook 1907.01, Appendix A.

4. RESPONSIBILITIES:

a. The Chief of Staff, through each Service Chief, is responsible for directing and supporting the efforts of the Health Information Manager (HIM) to collect accurate, complete, and timely documentation from health care providers in accordance with VANCHCS and Joint Commission standards.

b. Service Chiefs (Clinical and Ancillary) are responsible for ensuring that all documentation requirements in this Policy Statement are completed and/or authenticated by their health care practitioners. Additionally, they will ensure that inpatient attending physicians, physician assistants, 5.

February 5, 2019 nurse practitioners and other applicable clinicians coordinate with the HIM section to complete their health records.

c. The inpatient attending physician is responsible for, and must be familiar with, the care provided to the patient. The attending physician is expected to fulfill this responsibility, at a minimum, in the following manner:

(1) Direct the care of the patient and provide the appropriate level of supervision based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, and the experience and judgment of the resident, physician assistant (PA), or nurse practitioner (NP) being supervised. Documentation of this supervision will be via progress note, or countersignature of, or reflected within, the resident, NP, or PA progress note at a frequency appropriate to the patient's condition and for care involving residents in accordance with current VHA resident supervision guidelines.

(2) Meet, examine, and evaluate the patient early in the course of care (for inpatients within 24 hours of admission, within 48 hours for sub-acute admissions, and within 72 hours for long term care admissions) and document, in a progress note, concurrence with the resident, NP, or PA initial diagnoses and treatment plan. At a minimum, the progress note must state such concurrence and be properly signed and dated. In the case of a late entry, the date and time of the visit must also be included in the note to validate meeting the 24/48/72-hour requirement. For care involving residents, documentation must be in accordance with current VHA resident supervision guidelines.

(3) Direct appropriate modifications of care as indicated in response to significant changes in diagnoses or patient status. Evidence of this assurance will be documented via a progress note, or countersignature of, or reflected within the resident/NP/PA progress note.

(4) Assure that the appropriate information is present within the patient's health record at time of transfer to another VA/Non-VA facility, service, unit, and/or medical staff member.

Evidence of this assurance will be documented in the patient's record via a progress note, or countersignature of the hospital discharge summary, or reflected within the resident's progress note.

Refer to Policy Statement B&DMS-16, Referral and Transfer of Patients between Facilities, for additional requirements.

(5) Assure that discharge or transfer of the patient from the Sacramento VA Medical Center (SVAMC), Community Living Center (CLC), or clinic is appropriate based on the specific circumstances of the patient's diagnoses and treatment. At a minimum, evidence of this assurance will be documented by countersignature of the hospital discharge summary or clinic discharge note.

d. Health Care Practitioners and/or contributors to the health record, including physicians, dentists, nurse practitioners, physician assistants, registered nurses, and other allied health professionals, will complete their reports (signature/dictation) as required by this Policy Statement. All records will be completed no later than 30 days following discharge or outpatient clinic visit. Refer to attachment A for a documentation quick reference guide.

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e. Staff practitioners (outpatient) and attending physicians (inpatient) are responsible for reviewing the problem lists, and updating them on all patients assigned to them. Problems and operations/procedures will be recorded on the electronic problem list in CPRS, by physicians, dentists, house staff, physician assistants, and nurse practitioners.

f. The Health Information Management Section (HIMS) of Benefits and Data Management Service (B&DMS) is responsible for monitoring the medical record delinquency rate and for reporting findings to the VANCHCS Medical Record Committee.

g. Coding and abstracting HIMS staff are responsible for the review and abstraction of inpatient health records within 48 hours after receipt from the units. Deficient and delinquent records will be communicated to services and individual health care providers by weekly VistA or Outlook Exchange e-mail in order to ensure that the record is completed no later than 30 days following discharge.

h. All health care professionals are expected to enter their documentation electronically into CPRS, with the exception of those documents which cannot be entered electronically, such as those requiring patient signature or hand-written drawings. Special documents such as H&Ps, Operative/Procedure Reports, and/or Discharge/Death/Transfer Summaries may be dictated in accordance with Policy Statement B&DMS-29, Dictation Systems.

i. The contract transcription service is responsible for meeting and/or exceeding all established turn-around transcription times, including the accurate uploading of data into CPRS, as specified in the contract agreement and in Policy Statement B&DMS-29, Dictation Systems.

5. PROCEDURES:

a. Allergy or adverse reaction: Information may be entered in CPRS via the Orders tab or the Allergy/Adverse Reactions box via the Coversheet. NOTE: It must be available for view in CPRS in the top right corner of every tab in the Patient Posting box and on the cover sheet in the Postings box.

b. Evaluation and Management (E&M) Services: For E&M Services, e.g., office visits, consultations, etc., the nature and amount of physician work and documentation varies by type of service, place of service, and the patient’s status. History, examination, and medical decision-making are the three key components of an E&M service which are considered or validated to determine the appropriate level of the E&M service.

c. Inpatient Health Care: Health records must be complete and available for the provision of patient care according to the Medical Staff By-laws, but not greater than 30 calendar days from the date of discharge for inpatients.

d. Emergency and Urgent Care

(1) Urgent care and/or emergency documentation must contain the following components:

(a) Time and means of arrival;

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(b) Presenting problem(s), i.e., the reason for visit;

(c) History and objective data relevant to the presenting problem. NOTE: When not possible for patient to give history, the reason for this is documented;

(d) Assessment of the problem;

(e) Treatment plan for the problem;

(f) Primary and secondary diagnoses; i.e., only those dealt with at this encounter;

(g) Basis for ordering tests, consults, or changes in medication;

(h) Care received prior to arrival;

(i) Condition at discharge;

(j) Final Disposition;

(k) Discharge instructions;

(l) Whether the patient left against medical advice (AMA).

(2) Emergency care rendered for humanitarian reasons to a person who is not admitted must be documented in a patient record.

(3) When emergency care is provided, a copy of the record of emergency services provided must be made available to the practitioner or medical organization responsible for follow-up care.

(4) Documentation on Emergency Transfers. Documentation on emergency patient transfers to other organizations includes:

(a) Reason for transfer;

(b) Stability of patient;

(c) Acceptance by the receiving organization;

(d) Responsibility during transfer;

(e) Processing Dead on Arrival (DOA) Cases. NOTE: A person who is DOA is not to be shown on hospital records either as a gain or a loss. All administrative and medical documents prepared for the person who is DOA must be filed in the person’s health record.

(5) When a patient reports for care and leaves after triage by nursing staff and before examination by a Licensed Independent Practitioner (LIP), a LIP must review the triage documentation and determine whether an emergency existed and contact the patient when

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February 5, 2019 intervention must be rendered to protect the patient. In all cases, an addendum to the triage note must be completed to indicate the patient left before he or she was seen by a LIP.

e. Outpatient and/or Ambulatory Care:

(1) The health care practitioner must document a pertinent progress note at the time of each ambulatory and/or outpatient care visit. Clinicians should not enter notes on patient no-shows.

(2) The problem list must be initiated and maintained by the third visit by the health care practitioner and must include known significant diagnosis, conditions, pertinent past procedures, drug allergies, medications, and significant procedures performed outside VHA.

(3) The physician or health care practitioner must document only those diagnoses treated during an encounter or that require further treatment. An assessment as to whether continued care, on an ambulatory or outpatient basis, is required must be documented following the diagnosis.

(4) Elements for chronic disease indicators and prevention measures must be documented when appropriate.

(5) The physician must document a termination of care summary note when it has been determined that care is no longer required. The termination of care summary note must include: the condition on discharge, any patient instructions, and any relevant diagnoses, operations, and findings.

(6) Outpatient progress notes must contain the following components.

(a) Presenting problem(s), chief complaint or reason for visit;

(b) History and objective data relevant to the presenting problem(s);

(c) Assessment of the problem(s);

(d) Treatment plan for the problem(s);

(e) Diagnosis(es) treated during an encounter or that require further treatment;

(f) Reason (i.e., the medical necessity) for ordering tests, consults, or changes in medications;

(g) Follow-up treatment and patient instructions.

f. Outpatient Mental Health:

(1) Please refer to Policy Statement 11-16, Assessment/Reassessment of Patients for specific documentation and frequency requirements. All Mental Health (MH) patients have a Comprehensive Assessment completed upon initiation of treatment and updated annually by a Licensed Independent Practitioner (MD, NP, Psychologist, Licensed Clinical Social Worker. MH

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Specialty Care provide further in-depth assessments. History & Physicals are deferred to Primary Care.

(2) Progress Notes are completed by LIPs and include the presenting problem, assessment, interventions and planning.

(3) Group Notes include psychotherapy and educational groups.

(4) Recovery Treatment Plans are documented in a separate note titled as such and completed following the Comprehensive Assessment and updated annually or when the patient’s condition changes.

g. Initial Assessments:

(1) Members of the patient's care team must document initial assessments. Contents must meet the applicable Joint Commission requirements and/or specific VHA program regulations.

(2) Please refer to Policy Statement 11-16, Assessment/Reassessment of Patients, for specific documentation and frequency requirements.

(3) Educational needs, preferences, abilities, and readiness to learn are assessed on admission. The education process is interdisciplinary, as appropriate, to the care plan.

Documentation of education related to nutrition, nursing, and rehabilitation is required.

h. History and Physical (H&P):

(1) A complete inpatient admission H&P examination must be available within 24 hours of admission. In sub-acute care admissions, an H&P must be available within 48 hours of admission and in nursing home care; an H&P must be available within 72 hours of admission.

(2) An H&P, whether for admission or surgery, which is over 30 calendar days old is not acceptable and a new H&P must be documented. In nursing home care, an annual H&P must be completed.

(3) When documenting the physical exam, a check-off format is not acceptable.

(4) When recording the history, opinions of the interviewer ordinarily are not to be recorded in the body of the history.

(5) H&P examinations must be completed by clinical staff as delineated in facility Bylaws or by scope of practice.

(a) Prior to Admission, a durable legible copy of a physical exam performed within 30 days prior to admission may be used in the patient’s record, if there have been no changes in the patient or if the changes are documented at the time of admission. When the patient is readmitted within 30 days for the same or a related problem, an ‘interval’ physical exam reflecting any changes

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February 5, 2019 may be used, provided the original exam is readily available. In either case, an interval note must be completed indicating the following:

(1) Date original H&P completed;

(2) The H&P is still accurate;

(3) An appropriate assessment was completed on admission confirming that the necessity for the procedure or care is still present; and

(4) The patient’s condition has not changed since the H&P was originally completed, or any changes are documented.

(b) Prior to Surgery: An H&P must be available prior to surgery. When the H&P is done within 30 calendar days prior to surgery, the prior H&P may be used, but an interval note must be completed indicating:

(1) Date original H&P completed;

(2) The H&P is still accurate;

(3) That an appropriate assessment was completed prior to surgery confirming that the necessity for the procedure is still present; and

(4) That the patient’s condition has not changed since the H&P was originally completed, or any changes are documented.

(c) Emergencies: In an emergency, when there is no time to record the complete history and physical examination, a progress note describing a brief history and appropriate physical findings and the pre-operative diagnosis must be recorded in the health record before surgery.

(d) Annual Physical: When an inpatient has been hospitalized a year or longer, an annual physical examination must be completed.

(e) Ambulatory Care H&P:

(1) When a patient is first admitted for VA care on an ambulatory and/or outpatient care level, a relevant history of the illness or injury and physical findings must be documented in the patient record by the examining practitioner.

(2) If a patient is on ambulatory and/or outpatient care status for a year, at the time of the next visit, the patient must be given an assessment of the condition for which care is authorized. The examining physician must determine the comprehensiveness of the examination based upon the age, sex, and previous and current health status of the patient. The mental status of psychiatric patients must also be re-evaluated at the time of the annual physical.

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(f) Dental Surgery: Qualified oral surgeons may complete the H&P of dental and oral surgery patients admitted to Dental Service. For those patients admitted primarily for dental diagnoses and treatment, a history and clinical evaluation of the dental and/or oral problem must be completed by the admitting dentist. If the admitting dentist is a board-eligible or board-certified oral surgeon with H&P privileges, that person may perform and record the medical history and physical examination for that admission. If the admitting dentist is not an oral surgeon with H&P privileges, then a physician member of the medical staff must perform and record the H&P.

(g) Special Protocols:

(1) In addition to the H&P, special protocols, as prescribed in current directives, must be followed for certain patients such as former prisoners of war (POWs) and those who have alleged exposure to:

(a) Nuclear tests;

(b) Ionizing radiation;

(c) Agent Orange;

(d) Environmental contaminants; and

(e) Other events, chemicals, or substances as delineated by law.

(2) The performance of such examinations must be documented on appropriate forms and filed in the patient’s health record, or, if necessary, a record will be created.

i. Re-assessments: Re-assessments are completed when the patient’s physical, psychosocial, functional, or nutritional status significantly changes. All Resident Assessment Instrument (RAI) Minimum Data Sets (MDS) are transmitted to the Austin Corporate Data Center Operations (CDCO) where they are kept indefinitely.

j. Treatment Plan and/or Care Plan: An initial treatment plan, documented by the clinician, as part of the physical exam must be established on all patients within 24 hours of admission on acute care patients. In nursing home care, the initial treatment plan is documented within 14 days of admission; a plan of care is developed no later than 1 week after the initial assessment; i.e., within 21 days after admission. The care is planned and coordinated in a collaborative approach. Members responsible for providing care are identified in the care plan. The care plan indicates how frequently services are to be provided. Care planning recognizes advance directives and evidence of patient and/or family participation in developing and reviewing the care plan. Care plan goals are documented and the patient's response to care is evaluated when there is significant change in condition, or at least every 90 days for long stay admissions.

k. Laboratory and Imaging:

(1) Order entry for laboratory tests must be completed in full, clearly identifying the patient, location, requester, test date, special handling, and reason(s) for test.

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(2) Requests for tissue examination must contain the preoperative diagnosis and a brief clinical history, which includes the reason for the examination.

(3) Requests for imaging services must contain a complete reason for the exam with a brief clinical history.

(4) Reports of imaging results must reflect: patient identity; date performed; date interpreted; type, route, and amount of contrast or radio-pharmaceutical agents used, if applicable;

specific preparation of the patient; findings; and name of interpreter.

l. Progress Notes:

(1) General:

(a) Progress notes facilitate the communication among disciplines concerning the patient’s care. Members of the patient care team must document observations, progress, response to and changes in treatment, subsequent assessments of the patient’s response to care, other intervention, planned follow-up care, instructions, diagnosis and pertinent findings from ancillary tests. Progress notes must give a pertinent chronological report of the patient’s course. Progress notes may include, but are not limited to: a change in diagnosis(es), a change in condition, and/or a patient’s leave of absence. They may also include any justification for patient limitations.

(b) Clinical care must be documented in a progress note by the respective clinical staff as defined by their scope of practice.

(c) Documentation in the progress notes is required when there is a history of allergies, adverse reactions, or other conditions. The appropriate title must be used to trigger patient postings, as in CWAD.

(d) Inpatient progress notes must be written and signed in the computer at the time of observation, at a frequency appropriate to the patient’s condition, and in sufficient detail to permit continuity of care and transferability.

(e) Supervision of resident physicians must be documented by progress notes entered into the record by the staff physician or reflected within resident progress notes according to VHA Handbook 1400.1.

(2) Admission:

(a) The admission progress note must include: the type of admission, i.e., elective, emergency; chief complaint; a brief summary of the patient’s condition; and a tentative or differential diagnosis. VA Form 10-10m, Medical Certificate, may qualify as the admission progress note when it is prepared on the day of admission or immediately prior to admission.

(b) The staff (supervising) practitioner must meet, examine and evaluate the patient within 24 hours of admission, including weekends and holidays. Documentation of the supervising practitioner’s findings and recommendations regarding the treatment plan must be in the form of an

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February 5, 2019 independent progress note or an addendum to the resident note, which must be entered within 24 hours following admission. Staff admission progress notes must include findings and concurrence with the resident’s initial diagnosis and treatment plan as well as any modifications or additions. The progress note must be properly signed, dated, and timed. Staff practitioners are expected to be personally involved in the ongoing care of the patients assigned to them in a manner consistent with the clinical needs of the patient and the graduated level of responsibility of the trainee.

(3) Initial Clinic Visit. All new patients to the clinic seen by a resident must be seen by or discussed with the staff physician at the initial visit. This must be documented by the staff physician or reflected in the resident’s notes to include the name of the staff physician and the nature of the discussion.

m. Seclusion and/or Restraints: The physician must clearly document the necessity for each restraint or seclusion order in the progress notes. Please refer to the current policy on restraints, Policy Statement 11-55, for additional requirements.

n. Clinician to Clinician Shift Handoff:

(1) Standard data elements such as allergies, medications, problems, H&P, admitting diagnosis, labs, and consults are routinely communicated from physician to physician during a shift hand off or a transition in care. Transitions in care include changes in setting, service, practitioner or level of care.

(2) The “Shift Handoff Tool” in CPRS is the tool by which information is shared. Any text entered or modified in this tool is not retained permanently as part of the patient's health record. No information intended to be included in the permanent health record must be entered solely in this tool. Any information to be retained permanently must be entered in the appropriate location within the patient's health record.

o. Inter-service or Inter-Ward Transfer Note:

(1) The supervising practitioner, in consultation with the resident, ensures that the transfer of the patient from one inpatient service to another or transfer to a different level of care is appropriate and based on the specific circumstances of the patient’s diagnoses and condition. The supervising practitioner from the transferring service must be involved in the decision to transfer the patient and documentation of the appraisal must be entered into the health record. When a patient requires a different level of care within the same ward or unit, the supervising practitioner must be involved in the decision to change the level of care and documentation of the appraisal must be entered into the health record. The supervising practitioner from the receiving service must treat the patient as a new admission and must write an independent note or an addendum to the resident’s transfer acceptance note. This covers transfers into and out of intensive care units or transfers to extended care. The exception is if the same supervising practitioner is responsible for the patient across different levels of care, transfer documentation is not required.

(2) The content of this transfer note must provide a concise recapitulation of the hospital course to date, include the indications for transfer, and must be developed in a manner to assist the

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February 5, 2019 receiving unit, service, or medical staff member in providing continuity of patient care. The physician must document the transfer note prior to the patient’s transfer.

p. Discharge Progress Note and/or Discharge Instructions:

(1) The physician must complete a discharge progress note and/or instruction sheet for each period of hospitalization. It must contain date, the type of discharge, diagnoses, discharge medications, recommendations relative to diet, exercise, limit of disability, condition on discharge (to include character of surgical wound, if appropriate), place of disposition, recommendations for follow-up, and patient education. A CPRS discharge progress note template is available for this purpose, which must be entered separate from the formal discharge summary.

(2) When instructions are given to the patient or designee, the record needs to so indicate. A formal narrative summary (discharge summary) does not substitute for a discharge and/or instruction progress note.

(3) In cases involving death, the time and date when the patient expired, and the events leading to the death must be recorded by the physician. A CPRS progress note title “Death Note” is available with an associated template for this purpose.

(4) Any patient leaving against medical advice must have a final progress note written by a physician indicating any known reason for leaving and any special disposition arrangements.

q. Consultations and Referrals:

(1) Consultation:

(a) A consultation is a service performed for further evaluation and/or management of the patient (i.e., opinion and/or advice). The written request for a consult may be generated by a licensed independent practitioner, or as otherwise defined by Medical Staff By-laws, and documented in CPRS by using the consult request option. The request for consultation must include:

(1) A brief description of the patient’s condition;

(2) The reason for the consultation;

(3) Other information of value, such as, medication which may affect the condition being evaluated;

(4) The electronic signature of the requestor.

(b) The consultant’s opinion or advice must be expressed in a report that follows health record documentation requirements, i.e., who requested the consultation, what tests were ordered, the diagnosis, and treatment recommended. If the consultant initiates a diagnostic or therapeutic service in order to provide the opinion or advice requested, the service still qualifies as a consultation. Refer to VHA Handbook 1400.1, Resident Supervision, regarding resident supervision requirements when consultation services are performed by a resident physician.

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(c) The consultant's report of advice, opinion and any services that were ordered or performed must be documented in CPRS and the consult "closed." An appropriate note title that contains the word “Consult” must be assigned in CPRS in order to associate the current note with a pending consult request. The authenticated consultation report must contain:

(1) An opinion of the consultant's findings for making a diagnosis for a specific patient, or for providing treatment advice on a specific patient;

(2) An indication that the patient was examined;

(3) An indication that the patient’s record was reviewed;

(4) The date of the consult; and

(5) The consultant’s signature.

(d) Once the consultant assumes responsibility for the patient's continuing care, any subsequent services provided by the consultant are no longer a consultation. Further visits are reported as “established patient office visits.” The key here is whether:

(1) The primary practitioner retains control over management of the patient's care for the condition related to the consult, or

(2) The consultant assumes this responsibility.

(2) Referral:

(a) A referral represents a situation in which the primary practitioner feels that he or she is unable to treat the patient's condition and sends the patient to another practitioner for treatment.

Referrals, though often ordered through the CPRS consult request option, will not be coded or billed as consultation services.

(b) Referral for procedures, patient "walk-ins," and self-referrals are not considered a consultation. A practitioner cannot perform a consultation on the practitioner’s own patient unless it is for a pre-operative clearance; for example: A patient scheduled for a prostatectomy has previously had a myocardial infarction. The surgeon requests a consultation for pre-operative clearance from the cardiologist.

r. Observation Patients: An Observation patient is one who presents with a medical condition with a significant degree of instability or disability and who needs to be monitored, evaluated and assessed for either admission to inpatient status or assignment to care in another setting. In many instances, the patient is “observed” for an extended period of time without admitting them as an inpatient. The observation stay must be less than 48 hours. An admission note should clearly state the patient is being held for observation and orders should indicate “OBS”. Patients who after observation are found to need continued inpatient stay will be discharged from observation (with a brief discharge progress note and/or discharge summary entered into CPRS) and admitted as a full admission. Documentation will be recorded in CPRS, in accordance with Policy Statement 11-3

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February 5, 2019

Observation Program and VHA Directive 1036, Standards for Observation in VA Medical Facilities.

NOTE: Routine post-procedure recovery from ambulatory surgery is not considered ‘observation’ and therefore, should not be considered as such.

s. Informed Consent: All health records must include evidence that informed consent was obtained, when applicable, from the patient or authorized surrogate prior to undertaking any treatment or procedure and practitioners must document the informed consent discussion in the health record. Please refer to Policy Statement 11-61, Informed Consent for Surgery and Other Procedures, for specific requirements and details.

t. Anesthesia:

(1) Pre-anesthesia Evaluation: The pre-anesthesia evaluation must be documented by a qualified individual and must include:

(a) Patient Interview to review medical, anesthesia, and medication histories:

(b) Appropriate physical examination;

(c) Review of objective diagnostic data (e.g., laboratory, ECG, X-ray);

(d) Assignment of American society of Anesthesiologists (ASA) physical status;

(e) Formulation and discussion of an anesthesia plan with the patient and/or responsible adult.

(2) Pre-Induction Evaluation: The Anesthesiologist or Anesthetist must re-evaluate the patient immediately before anesthesia induction. This re-evaluation must be documented either in the Intra-Operative Anesthesia Record or a progress note. Notes must be annotated with the date and time.

(3) Anesthesia Plan: The anesthesia plan must be done by or show concurrence by an LIP with appropriate clinical privileges. LIP concurrence can be accomplished at the plan stage or the pre-induction re-evaluation.

(4) Post-Anesthesia Care Unit (PACU) Note:

(a) PACU documentation must include the patient evaluation on admission and discharge from the post-anesthesia care unit, a time-based record of vital signs and level of consciousness (either paper or electronic), all drugs administered and their doses, type and amounts of intravenous fluids administered, including blood and blood products, any unusual events including post-anesthesia or post-procedural complications, and post-anesthesia visits. This documentation generally is done by the PACU nursing staff. The health record must document the name of the LIP responsible for the patient’s release from the recovery room, or clearly document the discharge criteria used to determine release.

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(b) For inpatients, there needs to be at least one documented post-anesthesia visit after leaving the post-anesthesia care unit. The note needs to describe the presence or absence of anesthesia-related complications.

(c) For outpatients, Ambulatory Surgery personnel (i.e., a nurse) must call the patient after surgery, to assess any complications, including anesthetic complications, as appropriate.

u. Surgeries and Procedures: All aspects of a surgical patient’s care, including ambulatory surgery, pre-operative, operative and post-operative care, must be documented. Surgical interventions, diagnostic procedures, or other invasive procedure must be documented to the degree of specificity needed to support any associated coding data and to provide continuity of care.

(1) Pre-operative and/or Pre-Procedural Note. In all cases of elective and/or scheduled major surgery and or diagnostic and therapeutic procedures, and if circumstances permit, in cases of emergency surgery, the staff practitioner will evaluate the patient and write a pre-operative (pre-procedural) note describing the findings of the evaluation, diagnosis(es), treatment plan and/or choice of specific procedure to be performed and discussion with the patient and family of risks, benefits, potential complications and alternatives to planned surgery. When a resident completes the note, the supervising practitioner must write an addendum to the pre-operative note. Staff practitioners will be responsible for authorizing and/or approving performance of procedures.

(2) Immediate Post-operative and/or Post-Procedural Note. At times when there is a delay in the entry of an operation report or procedure report (such as when there is a transcription delay), a post-operative/post-procedure progress note must be directly entered into the patient’s health record (CPRS), by the surgeon immediately following surgery and before the patient is transferred to the next level of care.

(a) The immediate post-operative and/or post-procedural note must include:

(1) Pre-operative diagnosis;

(2) Post-operative diagnosis;

(3) Technical procedures used;

(4) Surgeons;

(5) Findings;

(6) Specimens removed;

(7) Complications.

(b) The immediate post-operative and/or post-procedural note may include other data items, such as:

(1) Anesthesia;

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(2) Blood loss;

(3) Drains;

(4) Tourniquet Time;

(5) Plan;

(3) Operative and/or Procedural Report. An operative and/or procedural report must be dictated or entered directly into CPRS and completed by the operating surgeon immediately following surgery. NOTE: Joint Commission defines immediately as “upon completion of the operation or procedure, before the patient is transferred to the next level of care.” This is to ensure that pertinent information is available to the next caregiver. In addition, if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be written in that unit or area of care. For procedures occurring in the Operating Room (OR), the report must be attached to the surgical case number under the surgery tab of CPRS, rather than under the progress notes section. When the report is dictated, an immediate post-operative/post procedural progress note must be entered as stated in section 5.s. (2) (a) above. The body of the operative report needs to contain indication for the procedure; operative findings; the technical procedure used; specimens removed; post-operative diagnosis; names of the supervising practitioner, primary surgeon, and assistants; and indicate the presence and/or involvement of the supervising practitioner.

(4) Level of Supervision. The “level” of supervision of such procedures must be documented in accordance with VHA Handbook 1400.1, Resident Supervision, and Policy Statement 11-14, Supervision of House Officers. The levels of supervision are described as follows:

(a) Level A: Attending Performing the Operation. The staff physician performs the case but may be assisted by a resident.

(b) Level B: Attending in OR, Scrubbed. The staff physician is physically present in the operative or procedural room and directly involved in the procedure. The resident performs the major portions of the procedure.

(c) Level C: Attending in OR, Not Scrubbed. The staff physician is physically present in the operative or procedural room. The supervising physician observes and provides direction.

The resident performs the procedure.

(d) Level D: Attending in OR Suite, Immediately Available. The supervising physician is physically present in the operative or procedural suite and immediately available for resident supervision or consultation as needed.

(e) Level E: Emergency Care. Immediate care is needed to preserve life or prevent serious impairment. The supervising physician has been contacted.

(f) Level F: Non-OR Procedure. Routine bedside and clinic procedure done in the OR.

The supervising physician is identified.

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(5) Recovery Room Note. Post-operative documentation (i.e., Recovery Room Note) must include: vital signs and level of consciousness; medications and blood and blood components; any unusual events or postoperative complications, including blood transfusion reactions; and the management of such events.

(6) Diagnostic and Therapeutic Procedure Reports. Detailed reports of diagnostic and therapeutic procedures not performed in the operating room must be documented in the progress notes by the practitioner performing the procedure, and must contain: the name of procedure; the name of the person performing procedure; details of performance; major findings and conclusions; if tissue was removed; any complications; a signature, a title, and a date. When a resident performs such procedure, the attending physician and degree of involvement must be clearly documented. In cases where there is a delay in entry of the formal procedure report (such as when it is dictated), an immediate post-procedure progress note must be entered as described in section 5. t. (2) above.

(7) Emergency Procedure Note. When residents are confronted with an emergency situation where immediate care is necessary to preserve the life of, or to prevent serious impairment of the health of, a patient and which involves a diagnostic or therapeutic procedure with significant risk to the patient, the resident is required to consult with the staff physician to obtain approval and authorization to proceed, and to determine who will be available to assist or to advise, as appropriate. This discussion must be documented in a progress note. A pre-procedural note must include details of the case, the name and nature of the discussion with the supervising practitioner, and the proposed procedure.

NOTE: If documented by a resident, it must indicate the name and approval of the staff physician who will be the attending surgeon in the operating room during the procedure.

v. Orders:

(1) General:

(a) All orders must contain the date, time the order was written, and the name of the practitioner placing the order; they must be signed and correspond to the individual’s scope of practice as defined by the Medical Staff By-laws.

(b) Applicable diagnostic information to justify the service ordered must be documented.

(c) Patients are discharged from the medical center, special care unit, urgent care, primary care clinics, and clinic services only upon order of the physician, Nurse Practitioner or Physician Assistant whose scope of practice specifically allows them to discharge on consultation with the supervising physician. Patients are discharged from the CREC only upon order of the physician.

(2) Medications. Medications must be identified by name, strength, route of administration, and frequency. For PRN medications, an indication is also required. Medication orders must be reviewed and rewritten when a patient is transferred between services and/or specialties, or is transferred to a critical care unit. Evidence of medication reconciliation must be documented upon

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February 5, 2019 any of the previously mentioned transfers or during any health event when medications are added or changed. Refer to VHA Handbooks 1108.05, Outpatient Pharmacy Services, and 1108.06, Inpatient Pharmacy Services, for more information.

(3) Verbal/Telephone Orders. Verbal Orders are strongly discouraged except in emergency situations.