D.23 - NMVAHCS – MCP 136-12 – Medical Records Management.pdf

New Mexico VA Health Care System Memorandum 136-12

Albuquerque, New Mexico April 23, 2015

136/JD/RW

MEDICAL RECORDS MANAGEMENT

1. Policy:

a. The Consolidated Health Record (CHR) will be created and maintained for every individual assessed or treated, as well as for those receiving community or ancillary care at VA expense;

veterans examined for possible exposure to toxins, asbestos, radiation or other environmental contaminants; those undergoing Compensation and Pension examinations; and collateral or family members of veterans attending counseling.

b. The medical record is the property of the medical center and is maintained for the benefit of the patient, the medical staff and the medical center. The medical record can be paper, computer based (electronic), or a combination of paper and electronic data. Electronic storage and capture of patient medical information will be implemented to the extent possible to enhance access to patient data by health care providers and support personnel. The electronically stored and/or printed patient information is subject to the same medical and legal requirements as the handwritten information in the CHR.

c. The most current standards of the Joint Commission will be followed, unless otherwise specifically stated by VA regulations or requirements as set forth by the Medical Staff Bylaws, Rules and Regulations.

d. Protection of confidentiality and privacy of patient information shall be ensured, including, but not limited to, compliance with Privacy Act of 1974, Freedom of Information Act (FOIA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Information contained therein will not be accessible to, or discussed with, unauthorized persons.

Authorized individuals must have an identifiable need for the record to perform their assigned duties. Please refer to Medical Center Memorandum (MCM) 002-17, Privacy Policy and MCM VA IT O&M-12, Internet Security Policy.

e. The borrower of a CHR paper record is responsible for its safekeeping, its availability and its timely return to the File Room. In the event the CHR paper record is transferred to another staff member or service, the borrower must ‘recharge’ (i.e. transfer responsibility for) the CHR paper record so its current location may be known at all times.

f. All medical record forms (paper and electronic), the overprinting, assembly and use thereof will contain, as minimum identification; the patient's name, social security number (SSN) and facility location (VAMC, Albuquerque, NM).

g. Only approved symbols and abbreviations will be used in the patient medical record.

Refer to MCM 136-11, Authorized and Prohibited Abbreviations for a complete list of approved and unapproved abbreviations. This applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.

h. Medical records will be made available upon request to the File Room.

i. All medical records will be filed according to the approved assembly and sequencing order. The medical record assembly and sequencing order will be updated and approved by the Medical Record Committee.

j. Medical records will be assembled and returned to the File Room by the close of business next day for all outpatient visits, daily appointments and special studies or audits.

Memorandum 136-12

Subj: Medical Records Management

April 23, 2015 2.

k. Following release of an inpatient, the medical record will be assembled on the unit and transported within 5 business days to the control of Health Information Management Section (HIMS).

l. The medical record received from an acute care admission into the Community Living Center (CLC) will remain on the floor for only 1 week prior to delivery to HIMS.

m. Records shall be kept and preserved for a period of time not less than that determined by the Records Control Schedule (RCS) 10-1 or when approval is received from the Federal Record Center (FRC) Director.

n. In the event of a disaster, patient records will be recreated based on available computer patient record information and/or hard copy records. If hard copy records are salvageable, they will be recovered and sent out to microfilm, in accordance with requirements in RCS 10-1. All records will be afforded protection against defacement, damage, loss, destruction by fire/flood or other hazards (Attachment C).

o. Medical records may be removed from the medical center's jurisdiction and safekeeping only in accordance with a court order, subpoena or statute. Medical records, however, will be transferred to another VA Medical Center or Community Based Outpatient Clinic (CBOC) upon request for purposes of maintaining a unit record.

p. Definitions:

(1) Active Record: The CHR of a patient who is currently receiving care, regardless of patient status or location of care being rendered.

(2) Addendum: Inclusion of additional information to source document.

(3) Ambulatory or Outpatient Care: Health care services provided to patients who are not classified as inpatients. For purposes of CHR maintenance, ambulatory or outpatient care refers to all categories of care such as Outpatient-Service Connected (OPT-SC), Outpatient-Non-Service Connected (OPT-NSC), Ambulatory Care, Home Based Primary Care (HBPC) etc.

(4) Authentication: Approval of documentation in the patient record by means of a signature (manual or electronic), computer key or other means recognized legally.

Authentication demonstrates the entry has not been altered and affirms the validity of the author’s actions(s), opinion(s) or statements. Authentication will consist of date, signature, initials or defined computer entry, time if required and professional designation of the member of the patient care team making the entry.

(5) Computer-Based Patient Record: An electronic patient record stored in Veterans Health Information System and Technology Architecture (VISTA), or other automated system using electronic storage system, e.g., optical disk that provides easy retrievability of complete, accurate, and timely medical information.

(6) Consolidated Health Record (CHR): The CHR (commonly referred to as the ‘Medical Record’) is the combination of the electronic and paper record. The CHR can be called the medical record, the patient record, the health record, the electronic health record and/or the computer-based patient record. The CHR contains two parts, housed in two folders:

(a) Type I, Administrative Records Folders; contains documents pertaining to a patient’s demographics, eligibility and other business-related documents.

http://vaww1.va.gov/vhapublications/rcs10/rcs10-1.pdf

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(b) Type II, Medical Records Folder; contains health care documents related to all aspects involved in healthcare delivery. It is individually identifiable data, in any medium, collected and/or directly used in documenting health care.

(7) Retired Record: A record stored off site, at a FRC, or archived to electronic storage medium. Records are retired after 3 years of inactivity or 2 years from date of death.

(8) Scan/Scanning: Capture of data via imagining/pictorial technology.

2. Responsibility:

a. The Medical Center Director and Chief of Staff Members are responsible for ensuring that processes are in place for the use of not only the paper CHR but the Computerized Patient Record System (CPRS) and that these processes are available and functional in a timely and accurate fashion. Data entry may be accomplished by various methods depending on the state of electronic evolution, finances, staffing levels etc.

b. Health Information Management Section (HIMS) staff are responsible for tracking and monitoring issues as they relate to patient medical record documents, paper and electronic.

Health Information Management Section (HIMS) staff members have continued responsibility for the amendment of documents that have been entered in error. It is the responsibility of HIMS to ensure that medical records of patients are available for patient treatment are properly completed, and maintained in compliance with standards established by VHA Headquarters and this medical center.

c. Chief Information Officer/Chief, VA Information Technology Operations and Maintenance (VA IT O&M) or designee is responsible for ensuring that software package parameters are set up in such a way as to facilitate ease and accuracy of documentation for the end user.

d. All medical center staff who utilize CPRS are responsible for maintaining, improving, and advancing their electronic skill levels. Employees are responsible for ensuring that documentation gathered and entered by them is accurate, appropriate and completed in a timely fashion. They are responsible for reporting any discrepancies, identified problems, etc. All staff members are responsible for following security and confidentiality standards described by the Network/Local security and confidentiality policies.

e. It is the responsibility of the clinical staff to document evidence of the patient's medical evaluation, treatment and change in conditions during the patient's hospitalization, or during an outpatient or emergency visit to the medical center.

3. Procedure:

a. General:

(1) The primary source of documentation for all patient care activities shall be CPRS.

New Mexico VA Healthcare System has established the goal of a transition to a paperless electronic medical record. Computer-generated medical record documentation does not currently eliminate the need for hard copies of specific patient medical records. The CPRS initiative is to achieve a complete electronic medical record.

(2) Medical and administrative processing of records, including qualitative and quantitative analysis, final coding and completion of deficiencies by responsible parties will be accomplished within established timeframes.

Memorandum 136-12

4.

(3) Each time a patient visits the ambulatory care setting, a progress note will be recorded preferably through CPRS. Documentation should include the following: date and clinic title, chief complaint, relevant history of illness or injury, clinical observations, results of treatment, reports of tests, procedures performed, doctor’s orders for medication, tests, therapy, work/activity limitations if any, diet when appropriate to clinical condition and follow-up, instructions to patient including level of understanding, signature and title of author.

(4) The problem list will be initiated and maintained by the third visit to the health care provider and shall include known significant diagnosis, conditions, procedures, drug allergies and adverse reactions. Entries other than diagnosis, if significant for the information of the health care team, may be recorded on the problem list. The health care problems listed will not be numbered and the list will be updated as necessary upon subsequent outpatient visits. Problems identified will be listed as chronic, acute or historic.

(5) The Clinical Reminder Package will be used to document the assessment and counseling of chronic disease indexes and preventative health issues. Information documented on this form will also be reflected in the visit progress note. The encounter form will be used to address clinical reminders pertaining to the relevant chronic disease index and preventative health issues.

(6) Each medical record will have at least the following component parts: Discharge summary history and physical examination, progress notes, vital signs, Doctor’s Orders, a comprehensive multidisciplinary treatment plan, and nursing care documentation. When applicable, the record will include informed consent or documentation of administrative consent, operation reports, pathology reports and autopsy findings.

(7) Medical records will contain original and/or electronically authenticated documents.

Signature, initials (where applicable), defined computer entry, professional designation, staff title and date will authenticate all entries in the record. The signature in the electronic record will be electronically timed stamped upon completion. Rubber stamp signatures are not authorized as the official signature.

(8) No edit or alteration of any documentation shall occur after manual or electronic signature has been completed. The only exception is through education of our house staff and students, i.e. discharge summaries and Podiatry medical student progress notes. Once the record is edited by the supervising physician, the document can no longer be edited or altered. Records will not be erased, white-out or marked-over. In CPRS documentation can be edited on line prior to authentication with an electronic signature. After a document is signed all corrections need to be done through the Privacy Act Officer or the Chief of HIMS (Attachment A).

(9) The Privacy Act of 1974 contains provisions for the amendment or correction of a medical record. In order to effect this requirement in CPRS, the Privacy Act Officer or Chief of HIMS will be provided a security key to access the computer-based record for purposes of amending or correcting the record.

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

(11) Medical records must, at all times, be immediately available for patient care. Paper medical records charged out of the medical center File Room must be kept in a highly visible but secure location. They will not be stored in a desk drawer or locked cabinet.

(12) Computer screens will be turned so that a passerby may not easily read the screen.

Individuals will not share computer access codes. When individuals are finished entering into the electronic record, they must make sure that they have discontinued access to VISTA; thus eliminating unauthorized access to patient information.

(13) When a patient is readmitted, the paper medical record containing the most recent episode of care will be made available by the File Room staff. Other records will be provided as requested. The final medical record will be maintained chronologically.

(14) Clinicians should refrain from re-entry of previously entered or captured data, such as cut and paste in CPRS or inserting copies into paper record (MCM 11-2, Cut Paste Policy for Electronic Notes). Avoidance of these practices ensures conveyance of most recent data, maintains record flow in an accurate contiguous manner and facilitates accurate and safe utilization of record by all clinicians.

b. Veterans Health Information System and Technology Architecture (VISTA) Downtime:

(1) Progress notes and consults may be handwritten to be filed in the paper chart or typed into a document, saved in a protected file and copy pasted into CPRS when it becomes available.

(2) Orders should be written on paper forms which Health Unit Coordinators and clinic support staff shall maintain supplies of for such emergent cases.

(3) Patient data will be available from contingency health summaries that contain predetermined information.

(4) Hand written notes may be back entered upon availability of CPRS or sent to the File Room for scanning.

c. Amendment of Medical Records:

(1) Electronic documentation (i.e., progress notes, discharge summary, etc.) may be amended at any time by the author or an expected co-signer prior to authentication.

(2) When a patient requests amendment of documents in his/her medical record, whether electronically generated or handwritten, the request must be referred to the Privacy Officer or Chief, HIMS.

(3) When original electronic documentation requires correction or amendment, the provisions of the Privacy Act of 1974, which apply to the correction or amendment of the original hard copy medical record, will be applied. Please refer to MCM 002-17, Privacy Policy for the amendment procedure.

4. References:

a. M-1, Part I, Chapter 5, Patient Records;

b. VHA Handbook 1605.1, Privacy and Release of Information;

c. M-3, Part 1, Chapter 9, Research and Development Requirements for the Protection of

Human Subjects;

Memorandum 136-12 Subj: Medical Records Management

6.

d. M-2, Part 1, Chapter 30;

e. VHA Handbook 1004.1, Informed Consent Procedures;

f. Records Control Schedule (RCS) 10-1;

g. The Joint Commission Manual for Hospitals;

h. VA Medical Center Bylaws and Rules and Regulations.

5. Rescission: Medical Center Memorandum (MCM) 161-46, Medical Records Management dated December 22, 2011.

6. Expiration Date: April 23, 2018.

Signed MCM in D/FMO File

Andrew M. Welch, MHA, FACHE Director

Attachments

Distribution “M”

Memorandum 136-12 Attachment A

CORRECTION TO MEDICAL RECORD DOCUMENTATION

1. PAPER RECORD:

a. If an error is made and correction is necessary to an entry within the paper record, the authenticator will draw a single line through each line of the inaccurate material.

b. The entry should be legible.

c. The person correcting the error should date and sign the correction (first initial and last name). Add a note, in the margin if necessary, stating why the entry is being corrected.

d. Enter the correct information in chronological order.

e. Indicate which entry it is replacing if the re-corrected entry does not immediately follow the error.

f. Record the date, time, and sign the new entry.

g. If there is any doubt as to the subsequent admissibility of the entry, it is a good practice to have a professional colleague witness the correction process. The witnessing need not be done for every minor error, but rather reserved for significant errors.

h. Wrong Patient Identification. There may be times when a patient identification stamp or label is applied to the wrong patient's paper chart but the information annotated on the paper chart is for the correct patient. When this occurs, we need to redact the wrong patient identifier information from the original document to avoid potential identity theft when releasing information to a first or third party requestor. To correct this error, the following steps will occur. Questions should be addressed to HIMS if an individual is still uncertain as to how to correct erroneous information.

• The incorrect stamp, label or handwritten patient identifier will be obliterated using a black ink pen or marker.

• The incorrect information will be replaced with a new Avery label with the patient's correct handwritten information or the machine generated patient label

• The individual correcting the document will place the date and their initial by the correction.

2. ELECTRONIC RECORD:

a. All clinicians should review computerized patient records before affixing their electronic signature to a document to assure information is correct. Notes are occasionally entered into VISTA by practitioners for the wrong patient, wrong clinic visits, etc. These notes should be addendum immediately upon discovery with directions to the viewer to disregard their contents.

b. To further prevent the ensuing provision of patient care by other practitioners based on erroneously entered clinical information, the notes will be retracted from active view. To preserve the clinical record in full, erroneously entered notes will NOT BE DELETED from VISTA.

c. The author may copy the note into the correct patient’s record or re-enter it.

d. The author will addend the note with information identifying it as erroneously entered and directing the viewer to disregard its contents.

e. The author will notify HIMS by sending an e-mail message in VISTA to G.PROGRESS

NOTE CHANGES or by calling the Chief Health Information Manager or designee.

When sending an e-mail message to the Text Integration Utility (TIU) Changes Mail Group for accurate identification of the note requiring action, the message must contain:

A-1 Memorandum 136-12 Attachment A

(1) Name of patient under whom the note was entered,

(2) Last four of patient’s SSN,

(3) Full progress note title of the erroneously entered note,

(4) Date and time of the erroneously entered note,

(5) Author, if other than the message sender, and

(6) Reason note is to be removed from view.

f. Health Information Management Section upon noting documentation is present, indicating that note is erroneous, will retract the note and respond to the e-mail message.

g. The title, body of the note, the author, date and time note was created will remain unchanged but will be removed from active view by VISTA users.

A-2 Memorandum 136-12 Attachment B

DEVELOPMENT OF NEW/REVISED OVERPRINTED FORMS/TEMPLATES

1. The initiating department will prepare a sample form for approval by the Chair or Assistant

Administrator of that department and obtain concurrence by the Chair or Assistant Administrator of any other department involved in the completion of new form.

2. Approval/concurrence signifies the intent of the overprinted form is clear, can be implemented, does not conflict with accepted practice of their discipline, and is in keeping with the accepted standards.

3. The form, documentation of concurrence and completed Repetitive Form Letter (Rept. FL

003-207, Request for New or Revised CPRS Progress Note, Template, will be forwarded to the Directive/Forms Management Officer (D/FMO-(IT)) for compliance review and approval in conjunction with the Forms Sub-Committee of the Medical Record Committee. If this is a revision of a prior existing form, a copy of the old form must also be included.

4. The D/FMO will assess form for inclusion as a computerized form in CPRS and ensure that such a form does not already exist. If appropriate, the requesting department will be contacted when the form is activated in CPRS.

5. Forms that cannot be computerized will be forwarded to Office Operations Section

(RFMS/136C2) for reproduction authorization and assignment of a form number.

6. Forms that cannot be computerized will be processed as hardcopy by the D/FMO for assignment of form number, placement on intranet website and instruction on Reprographics Request procedures.

7. If the overprint is deemed inappropriate, or a duplication of an existing form the individual submitting the request will be contacted by D/FMO for resolution.

B-1 Memorandum 136-12 Attachment C

PROTECTION OF MEDICAL RECORDS FROM WATER DAMAGE

Paper medical records may be subjected to widespread or localized damage from rising water, as in the case of flood or broken water mains, or falling water, such as from leaking or broken pipes or fire sprinkler activation. Following such an emergency, water-damaged records require special attention to restore them to their original state. Even though it is the policy of this medical center to maintain medical records in such a way as to prevent any form of water damage, this attachment details procedure to follow in the event of such an occurrence.

1. PROCEDURE:

a. Rising Water: Widespread damage may be caused to medical records housed on the ground level due to flooding during or following extreme rain conditions or broken water mains.

(1) Medical records will be maintained in an area that is unlikely to flood or be subjected to damage from water.

(2) Upon notification that it is likely that the surrounding vicinity will be subject to flooding and the medical record file room is likely to be flooded:

(a) All efforts within human possibility will be made to move records to an area that is unlikely to be subjected to water damage. Personnel will not be subjected to conditions that would expose them to danger to their life or health.

(b) All electronic equipment will be turned off. Equipment will be moved to a dry location that is unlikely to be affected by water damage.

(c) To protect the confidentiality of medical records during a flooding crisis, the area will be secured and only authorized personnel will have access to the area.

(d) Floodwaters are often mixed with sewage, animal waste, fertilizers and/or industrial waste, and should be considered a biohazard. Employees will not be allowed to re-enter the flooded area until all freestanding water has been removed and the area is thoroughly cleaned by the Environmental Management Service.

b. Falling Water: Widespread or localized damage may be caused to medical records due to a leaking or burst pipe or malfunctioning fire sprinkler.

(1) Paper medical records will be maintained in file shelving units that have a canopy top.

Paper medical records will not be stored on top of filing cabinets or on the floor.

(2) Upon notification of a leak or malfunctioning fire sprinkler:

(a) Shelving units in danger will be covered with plastic. A supply of plastic sheeting will be obtained from Engineering Service. After the threat of water damage has passed, all plastic will be removed.

(b) Computer equipment and any other machinery or furniture may also be covered with plastic to minimize damage, as time permits after the threat to medical records has been minimized.

(c) Environmental Management Service will be contacted to supply appropriate receptacles to catch water, absorbent materials to soak up water, vacuum water and thoroughly clean and dry the affected area.

C-1 Memorandum 136-12 Attachment C

c. Recovery/Restoration: Should paper medical records sustain water damage, a quick response will be required to recover their contents intact. Paper records left wet for any significant length of time are at risk of unrecoverable damage due to disintegration, tearing, smearing or mildew/mold growth. Depending on the volume of records involved, full recovery may be realized with a local effort only, or may require more extensive measures, such as a contract with a water damage restoration company.

(1) If a small quantity of records is wet from a clean water source, authorized personnel must respond immediately to:

(a) Carefully remove the records from the shelves and gently pat dry as much as possible;

(b) In a secure location, separate each record on a clean, dry, flat surface for the paper to thoroughly dry;

(c) Print any electronic documentation that may be required to reconstruct damaged pages;

(d) Reassemble each record in the approved filing sequence;

(e) Thoroughly dry the file shelves; and

(f) Replace the records on the shelves in the correct terminal digit order.

(2) If a large quantity of records is wet or if the water source may be contaminated, such as in the case of flood water:

(a) A water damage restoration company should be contacted immediately upon discovering the damage and an emergency purchase order be secured for their services.

(b) Any contract for water damage restoration services should specify the method of recovery, the time that will elapse between acquisition and return of the records, and safeguards against breaches in confidentiality.

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