D.19 Document Scanning Policy 02.pdf

D.19 Document Scanning Policy 36C25923R0040

DOCUMENT SCANNING

Eastern Oklahoma VA Health Care System Muskogee, OK 74401

Signatory Authority:

Chief, Business Office

Responsible Owner:

Chief, HIMS

1. PURPOSE AND AUTHORITY

SOP 161-B-10

Service Line(s):

Business Office

Effective Date:

May 29, 2022

Recertification Date:

June 30, 2027

a. The purpose of this standard operating procedure (SOP) is to establish procedures on for health record document scanning and/or importing documents/images related to patient care in VistA Imaging. This SOP applies to administrative and clinical documents and covers all organizational entities including Community Based Outpatient Clinics within Eastern Oklahoma VA Health Care System

(EOVAHCS).

b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 1907.1, VHA Information Management and Health Records dated April 5, 2021, and VHA Directive 1065, VHA Privacy Program dated September 1, 2017.

2. PROCEDURES

a. Requesting Non-VA Documents for Scanning.

(1) Non-VA documents may be maintained as part of the patient’s VHA permanent health record at the practitioner’s written request. A provider cannot give a verbal order to a clerical staff member to scan any documents into a Veteran’s medical record.

(2) The provider must complete the “Request to Scan Non-VA documents” (See Appendix A). The provider is responsible for the identifying the note title that the document must be attached or for making a new note under the title “Outside Medical Records” which will verify the document was reviewed by the provider and the provider concludes that information should be incorporated into the patient’s medical record.

(3) In lieu of scanning any external source documents, the progress notes titled “Outside Medical Records” written by a clinician after a review of the external source documents, may also be used to summarize the content.

b. Scanning on Non-VA Purchased Care/CCN Documents Only.

May 29, 2022 SOP 161-B-10

(1) Receive Clinical Documentation. Check all applicable methods for documentation exchange in the order they are received by local facility to confirm delivery of clinical documentation; JLV, e-Fax, US Mail, HSRM.

(2) Review and identify the appropriate consult related to the received clinical documentation.

(3) Check Quality of clinical documentation file. View Document and Quality Check.

(a) All pages are for the same Veteran

(b) Documents are authenticated (written or electronic signature) by the external provider

(c) Documents are readable and legible

(d) Duplicate document or image

(e) Pages are not blank or misaligned

(4) Save Clinical to Shared Location. Once clinical documentation has passed Quality Checking and have been downloaded or scanned from the applicable documentation exchange tool, the documents should be saved to a shared folder in preparation for importing and indexing into VistA Imaging Capture. Documents should be named according to a standard naming convention established by local policy (e.g., Last name, first initial of first name, last 4 of SSN, date of service, Specialty).

(5) Import and Index to Clinical Documentation to VistA Imaging Capture.

(a) Open VistA CPRS and select File and “Select New Patient”

(b) Locate the Veteran from the patient list and click OK

(c) Access VistA Imaging Capture by clicking on Tools and selecting “Image Capture”

(d) In VistA Imaging Capture, select the Import option

(e) Right click the gray box and select “Import Directory Options”. This allows the user to set the new path as the default directory.

(f) Select and import the desired Veteran files

(g) Once the documents(s) are imported, a list of index fields will appear

(h) Fill out all index fields and click the Capture button

(i) Click OK to save the document

(j) Remove/delete file from shared folder (if applicable) after importing into VistA Imaging Capture

(6) Complete Consult Closure Note. The facility community care (clinical staff) will receive the incoming documentation, review the documentation for clinical appropriateness and care coordination, designate the appropriate consult (or Community Care EMER Self Presenting Care Coord Plan note that it should be attached with, or create a new Consult request and then write a summary note for the referring VA provider’s notification and review of the completed consult). If facility community care attaches the documentation to a Consult, using the COMMUNITY CARE CONSULT RESULT note, the consult will close/complete so that the alert goes to the appropriate VA provider. Facility community care MSA staff are responsible for performing a review of the incoming documentation designated as Low Risk Clinics.

c. General Guidelines for Scanning.

(1) The provider can either write a progress note that details the outside records findings or complete the “Request to scan Non-VA Documents” form and attach it to the outside records. The scanning staff will then scan the request and the documents into the medical record.

(2) The staff member responsible for scanning the documents must verify that the following information is provided on the document before scanning: patient’s full name, last four digits of the Social Security Number (SSN), and/or the date of birth (DOB) of the patient.

(3) Digital image captures must meet the same criteria of patient identification as scanned documents. However, some paper and digital images received form sources outside VHA, such as private hospitals or physician offices do not contain all the identifying data required of VA-generated documents. In the case of electronically received images, the first page must include, at a minimum, the patient’s name and last four digits of their SSN before importing into VISTA Imaging. Each subsequent page needs to contain, at a minimum, enough identifying traits to clearly identify the patient. In the case of a large quantity document set (anything over 25 pages) received, the full name, last four digits of the SSN, and DOB can be written on the first and last page of the document set in lieu of adding the patient’s name, last four digits of the SSN and/or DOB to every page when scanning as a complete set.

(4) Photographs must include the patient identifier but may not be able to accommodate the identifier when taking a close-up photograph, such as a wound.

Therefore, when photographs cannot capture the patient identifier, take a picture with the patient identification (name, last four numbers of the SSN, DOB), such as on an index card with the information to be used as the first image in the study. Then take the close-up picture(s) of the body or area. Finally take another identification picture at the end. The identification pictures must be the first and last picture in the series with the non-identified close-up pictures in the middle. NOTE: It may be beneficial to take a wide-angle picture(s) before the close-up pictures when possible.

(5) VHA requires received medical documents to be reviewed by the patient’s medical provider and scanned into the electronic medical record within 5 business days of the received date.

d. Data Capture and Image Linkage.

(1) Documents must be captured in VISTA Imaging in a consistent manner and the integrity of the document must be maintained as with the paper medical record documents.

(2) Images must be linked to the correct provider’s progress note for a specific visit date or by provider’s creation of a progress note (using “Outside Medical Records” note title/template) that is specific to the scanned document.

e. Indexing.

(1) The documents scanned into VistA Imaging Capture will have consistent index terms to allow for proper sorting and searching of scanned documents by clinicians and administrative staff. The staff member will utilize the Index Reference Guide to determine indexing terms (See Appendix C). If a document is not listed in the guide provided, the staff member will contact the Chief of HIMS for clarification before the image or document is scanned into the medical record.

(2) Quality checks of 100% of all indexed images will be completed by all staff indexing records of any type including Community Care Network. Chief, HIMS will delegate staff to ensure this occurs with Business Office staff. Team Lead MSA’s and Asst. Nurse Manager in CCN will ensure this process occurs with CCN staff.

f. Administrative Documents.

(1) Administrative documents/images will be captured by attaching the scanned image directly to the patient’s administrative record instead of a progress note and indexed with appropriate administrative indices (See Appendix C). Administrative documents scanned to the patient’s administrative record will be viewable by individuals who possess administrative access keys in VistA Imaging. Before administrative access keys can be issued, the individual’s service Automated Data Processing Application Coordinator (ADPAC) will need to obtain approval from HIMS.

g. Retention and Destruction of Original Paper Scanned Documents.

(1) The retention of original documents will be in accordance with VHA Directive 1907.01, “Health Information Management and Health Records” and VHA Record Control Schedule 10-1, which allows the VA to destroy original source documents “after scanning as long as the person doing the scanning performs a 100 percent review of each scanned document during the scanning process for quality control purposed to ensure it is readable and retrievable for health record retention.”

h. Scanner Training.

(1) Scanner training is required for all staff responsible scanning records into VistA.

Documents scanning training shall be conducted prior to allowing an employee to scan documents without direct supervision. When the employee scans a minimum of twenty consecutive documents error free, they will have successfully completed training and will be able to scan with limited supervision.

(2) CCN staff are required to complete scanning training as well and will also be trained by CCN Training Specialist before indexing without supervision.

i. Conducting Quality Assurance Reviews.

(1) The service line supervisor of the staff responsible for scanning into the medical record will do quarterly quality review of scanned documents and report the data to the Medical Records Committee monthly.

(2) All scanned documents will also be concurrently reviewed by each individual responsible for scanning to ensure that documents scanned into the patient’s medical records are accurate and legible.

(3) The HIM Supervisor and/or designed will do a randomized quality review each month of a number of scanned documents. The total of the reviewed scanned documents is set by the Joint Commission standards. The quality review will include the following:

(a) Name of the person scanning the document(s)

(b) The date the document(s) were scanned

(c) Is the patient’s full name visible?

(d) Is the patient’s last 4 of the Social Security Number visible?

(e) What is the document form/type?

(f) Is the correct patient’s name on every page?

(g) Is the document indexed properly?

(h) Is the document positioned correctly?

(i) Is the document legible?

(j) What is the turn-around time (TAT) for each document set?

(4) The HIMS Supervisor will report all quality review findings to the Medical Records Committee.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Chief, Business Office. The Chief, Business Office is responsible for:

(1) Acting as the primary point of contact in document scanning.

(2) Ensuring that the integrity of the medical records is maintained by providing properly scanned images that are legible and scanned in a timely manner.

b. Chief, Health Information Management Service (HIMS). The Chief, HIMS is responsible for:

(1) Ensuring that all staff with scanning responsibilities is properly trained to capture documents into VistA Imaging, using VistA Imaging Capture.

(2) Informing staff of new updates of software, patches, and changes in current policies/procedures as communicated from Office of Information and Technology & Technology (OIT) and Clinical Applications Coordinators (CAC) specific to scanning software.

(3) Identifying and reporting all computer related problems to OI&T and suggesting recommendations to applicable parties to ensure the scanning process is streamlined.

(4) Generating the VistA Imaging Monitor report to the productivity of each employee responsible for scanning.

(5) Performing quarterly Quality Image Assurance Monitoring.

(6) Reporting quarterly to the Medical Records Committee of compliance and findings.

c. All employees. All EOVAHCS employees who are involved with document scanning are responsible for:

(1) Completing required training for document scanning.

(2) Scanning documents in a timely manner with quality and integrity.

(3) Performing concurrent and retrospective quality checks of all scanned documents.

(4) Reporting any errors to the Service Chief or immediate Supervisor.

(5) Sending an email to the Chief of HIMS or designee specialist responsible for removing scanned documents errors.

(6) Adhering to any new changes in policies/procedures or training methods related to Document Scanning/VistA Imaging, and VHA Directives.

d. OI&T. The OI&T staff are responsible for:

(1) Assisting in setup of scanning equipment (i.e., software), and issuance of scanning keys.

(2) Informing the services, who currently scan documents, of new functionalities, updates, and/or changes in technology (i.e., installation of new patches).

4. DEFINITIONS

a. Health Record. A health record includes the electronic health record and the paper record, combined, and is also known as the legal health record. A health record can be comprised of two divisions, which are the:

(1) Clinical Health Record. The clinical health record is the documentation of all types of health care services provided to an individual, in any aspect of health care delivery. A clinical health record includes individually identifiable data, in any medium, collected and directly used in or for documenting health care. The term includes records of care in any health-related setting used by health care professionals, while providing patient care services, to review patient data or document their own observations, actions, or instructions. The clinical health record includes all handwritten and computerized components of the documentation.

(2) Administrative Health Record. The administrative health record is an official record pertaining to the administrative aspects involved in the case of a patient, including demographics, eligibility, billing, correspondence, and other business-related aspects.

b. Scanning. Scanning is the digitalization of documents and data using imaging or pictorial technology. Document scanning, or document imaging, is a process by which a paper document is converted to an electric file.

c. Scanned Documents. Documents that are indexed, scanned, or imported into the VistA Imaging System and accessed via the VistA Imaging Display tab under the CRPS tool drop down box.

5. REFERENCES

a. VHA Directive 1907.01, VHA Heath Information and Health Records, dated April 5, 2021, https://www.va.gov/vhapubllicatons/publications.cfm?Pub=1=1907.01.

b. VHA Directive 1605, VHA Privacy Program, dated September 1, 2017, https://www.va.gov/vhapublications/publications.cfm?Pub=1&order=asc&orderby=pubNu mber=1605.

c. VistA Imaging System Technical Manual, https://www.va.gov/vdl/documents/Clinical/VistaImagingSys/imgtechmanf.pdf.

https://www.va.gov/vhapubllicatons/publications.cfm?Pub=1%3D1907.01 https://www.va.gov/vhapublications/publications.cfm?Pub=1&order=asc&orderby=pubNumber%3D1605 https://www.va.gov/vhapublications/publications.cfm?Pub=1&order=asc&orderby=pubNumber%3D1605 https://www.va.gov/vdl/documents/Clinical/VistaImagingSys/imgtechmanf.pdf

TRISHA

BARRETT

Digitally signed by TRISHA

BARRETT

Date: 2022.08.24 14:17:05

-05'00'

Digitally signed by CARRIE

CARRIE TERRY TERRY Date: 2022.08.24 13:12:33

-05'00'

d. VistA Imaging Security Guide, https://www.va.gov/vdl/documents/Clinical/Vista_Imaging_Sys/IMGsecgd.pdf.

e. Record Control Schedule (RCS-1), https://www.va.gov/vhapublications/RCS10/rcs10-1.pdf

f. The Joint Commission Comprehensive Accreditation Manual, https://e-dition.jcrinc.com/MainContent.aspx

6. REVIEW

This SOP will be reviewed, annually, at minimum at recertification, when there are changes to the governing document(s).

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of June 2027.

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

8. SIGNATORY AUTHORITY

TRISHA BARRETT

Chief, Business Office Date Approved:

CARRIE TERRY

Chief, HIMS Date Approved:

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

Attachments: Appendix A: Request to Scan Non-VA Documents Appendix B: Non-VA Purchase Index Guide Appendix C: Index Reference Guide

DISTRIBUTION: SOPs are available at EOVAHCS SharePoint Site:

https://dvagov.sharepoint.com/sites/mus/sop/SitePages/Home.aspx.

08/24/2022

08/24/2022 https://www.va.gov/vdl/documents/Clinical/Vista_Imaging_Sys/IMGsecgd.pdf https://www.va.gov/vhapublications/RCS10/rcs10-1.pdf https://e-dition.jcrinc.com/MainContent.aspx https://e-dition.jcrinc.com/MainContent.aspx https://dvagov.sharepoint.com/sites/mus/sop/SitePages/Home.aspx

A-1

APPENDIX A

REQUEST TO SCAN NON-VA DOCUMENTS

Department of Veterans

REQUEST TO SCAN NON-VA DOCUMENTS

Please attach the documents you wish to have scanned and check the appropriate boxes. We will only scan the documents that you attach to this checklist. Paper records are no longer filed. Any outside documents not specifically designated for scanning by a clinician will be destroyed. We will scan documents checked below.

FROM (Name of Hospital, HMO, or Doctor where care was provided)

1) TEXT DOCUMENTS

❑ Hospital Discharge Summary

❑ History & Physical

❑ Emergency Room Notes

❑ Progress Notes

❑ Medication List

❑ Chiropractic Notes

❑ Consult Reports

❑ Correspondence (type)

2) DIAGNOSTIC TESTING

❑ Pathology reports

❑ Radiology Reports

❑ Mammogram

❑ Nuclear Medicine Scans

❑ EKG

❑ Cardiac Stress Test

❑ Echocardiograms

❑ EEG

2a) DIAGNOSTIC

TESTING (continued)

❑ EMG

❑ Nerve Conduction Study

❑ Pulmonary Function Test

❑ Allergy Testing

❑ Other

❑ Other:

3) OPERATIONS

❑ Operation Report

❑ Anesthesia Record

❑ Open Heart Perfusion Data

❑ Myocardial Preservation Data Sheet

❑ Pacemaker Device Report

4) PROCEDURES

❑ Endoscopy

❑ Colonoscopy

❑ Sigmoidoscopy

❑ Cardiac Catheterization

❑ PTCA Report

❑ Other:

Clinician’s Signature

Date

Clinician’s Printed Name and Title

PATIENT NAME AND SSN#

MEDICAL RECORD

Request to Scan Documents

SUPPLEMENT TO PROGRESS NOTE FOR

SPECIALIZED DISCIPLINES-VERTICAL

VA FORM 10-0114g OP # 793 (CPRS) 08/04

APPENDIX B

B-1

NON-VA PURCHASE INDEX GUIDE

B-2

B-3

APPENDIX C

C-1

INDEX REFERENCE GUIDE

WO FORM DOCUMENT

IMAGE DATE

DOCUMENT

IMAGE TYPE

SPECIALTY PROCEDURE/EVENT IMAGE

DESCRIPTION

SPECIAL

INSTRUCTIONS

Denied Non-VA Claim

Denial Letter Date of Service

Denial Letter

N/A

Facility name that performed the service

Correspondence

Authorization of care, Appeal Rights, etc.

Date of Service

Correspondence

Description of the document

Include with Denial letter.

Can scan as denial letter appeal rights

FEE-ADMINISTRATIVE

C-2

DOCUMENT

(ORIGIN:

FEE)

FORM DOCUMENT

IMAGE

DATE

DOCUMENT

IMAGE TYPE

SPECIALTY PROCEDURE/EVENT IMAGE

DESCRIPTION

SPECIAL

INSTRUCTIONS

Ambulatory Operative Date of Procedure Choose Choose appropriate Facility name Surgery Report and Procedure Record/Report specialty of procedure/event for that performed

Pathology clinician the specialty selected the ambulatory Report performing surgery surgery

Compensation Compensation Date of C & P Exam Choose Choose the Facility name & Penstion & Pension Consult Report specialty or appropriate that performed

Exams (DES) subspecialty procedure/event for the of clinician the specialty consultation performing service and the service identify the C&P exam that was performed.

Consult Attach the Date of Consult Choose Choose the Facility name captured Consult specialty or appropriate that performed document to subspecialty procedure/event for the the of clinician the specialty consultation consultation performing service the service

Dental Treatment Date of Consult if Dentistry Choose the Facility name VAF-2570d contains plan (VAF- procedure or there is a appropriate that performed both administrative 2570d) and/or date of last consult or procedure/event for the dental (financial) and clinical progress treatment on Procedure the specialty service information. Although notes summary Record/Report the preferred practice note if there is not a would be to scan consult VAF-2570d as an administrative document, it may be the exception and scanned as part of the clinical record due to its longstanding use as a clinical document.

Dialysis Notes Monthly Date of last Consult if Nephrolgoy Dialysis Facility name summary note treatment on there is a that performed with dates of summary consult or the dialysis and treatment note Procedure the date range provided. Record/Report of treatment if there is not a consult

Emergency ER Report; Date of ER Medical Emergency Visit Hospital name Room Laboratory; Visit Record Medicine for the Records Radiology emergency room visit

Laboratory Laboratory Date Procedure Laboratory Reference Lab Test name. The image (not Report and specimen Record/Report description field is Anatomical final result (s) was taken limited to 60 Pathology) characters.

Additional information can be entered in the image long description if needed.

FEE CLINICAL

C-3

Mammography Mammography

Report Date of mammography

Procedure Record/Report

Radiology Mammography Facility name that performed the procedure and the name of the procedure

Medical Oncology

Summary report to include drug regimen, how often given, if interrupted

Date of last treatment on summary note

Consult if there is a consult or Procedure Record/Report if there is not a consult

Oncology Choose appropriate procedure/event for the specialty selected

Facility name that performed the oncology service and the date range of treatment

Outpatient Procedures

Example:

Colonoscopy -procedure note, findings, any final biopsy results

Date of procedure

Procedure Record/Report

Choose the specialty of the clinician performing the service

Choose appropriate procedure/event for the specialty selected

Facility name that performed the outpatient procedure and the type of procedure performed

Outpatient Visit Progress note from outpatient visit

Date of the outpatient visit

Consult if there is a consult or Procedure Record/Report if there is not a consult

Choose the specialty of the clinician performing the service

Visit Facility name that performed the service

Pathology Anatomical, Surgical and Cytology

Laboratory Report and final result

Date specimen was taken

Procedure Record/Report

Pathology Reference Lab, Referral, Joint Pathology Center (military lab) Autopsy, Cytology

Facility name and name of the specimen (body part, blood, etc.)

Procedure report and pathology report (excluding Anatomical Pathology)

The procedure report and pathology report (should receive pathology report whether negative or positive), i.e., within 48 hours. If the procedure report and pathology report are received together, scan as indicated. If the documents are received separately, scan separately as Pathology and Procedure as above.

Date of procedure

Procedure Record/Report

Choose the specialty of the clinician performing the procedure

Choose appropriate procedure/event for the specialty selected

Facility name and name of the specimen (body part, blood, etc.)

Radiation Therapy

Summary report to include drug regimen, how often given, if interrupted, type of radiation, amount of radiation and location of treatment.

Date of last treatment on summary note

Consult if there is a consult or Procedure Record/Report if there is not a consult

Radiation Therapy

Radiation Therapy

Facility name that performed the radiation therapy and the name of the body part treated

Radiology Studies Date of

Procedure Record/Report

Radiology or Nuclear Medicine

Choose appropriate procedure/event for the specialty selected

Facility name that performed the procedure and the name of the

Rehabilitation Therapy

Notes Date of last treatment on summary note

Consult if there is a consult or Procedure Record/Report if there is not a consult

Rehabilitation or Speech Pathology

Choose the appropriate therapy, i.e., Physical Therapy

Facility name that performed the therapy and the date range of the treatment

C-4

Acute Inpatient Admissions

Inpatient stay Date of Discharge Medical Record Choose Specialty of Clinician, NOT the ward

Inpatient Stay

Hospital name for inpatient stay

Community Living Centers (CLC)

Inpatient stay Date of Discharge Medical Record Choose Specialty of Clinician, NOT the ward

Inpatient Stay

Facility name for inpatient stay

Community Nursing Homes

(CNH)

Inpatient stay Date of Discharge Medical Record Choose Specialty of Clinician, NOT the ward

Inpatient Stay

Facility name for inpatient stay