D.24 Downtime procedures.pdf

From: Kendrick, Tammy R SAMVAMC To: Divers, Jennifer J. SAMVAMC Subject: RE: Downtime procedures Date: Friday, February 12, 2021 9:27:27 AM Attachments: FORMS IN CONTINGENCY SITUATION.doc

Code 10.pdf

qq. Contingency Plans:

(1) Providers must not keep records in their work areas any longer than necessary. VHA handbook 1605.1 bars care providers from keeping permanent records stating “….no personal copies of VHA records can be maintained by VHA employees…”

(2) During unexpected computer downtimes or Code 10s, the Chief, HIMS will determine, in collaboration with Nurse Managers and Preceptors, what documents will be scanned. The Scanning Coordinator will provide technical and subject matter expertise to facilitate the process. At a minimum, flow sheets, reports, and medical documents which realistically cannot be entered in to CPRS once computers are back on line will be scanned.

Department of Veterans Affairs VAMC MEMORANDUM 658-136-30 VA Medical Center December 27, 2017 Salem, VA 24153 Management of Electronic Health Records Document Scanning

D.24 Downtime procedures 36C24621R0068 mailto:tammy.kendrick1@va.gov mailto:JENNIFER.DIVERS@va.gov

Link below to Forms website- at the bottom of page you can get to link for the SF forms (standard forms).

http://vaww.va.gov/vaforms/

SF503

Medical Record - Autopsy Protocol

07/2000

SF504

Medical Record - History

02/2001

SF505

Medical Record - History - Parts 2 and 3

12/2002

SF506

Medical Record - Physical Examination

02/1999

SF507

Medical Record

07/1991

SF508

Doctor's Orders

03/1994

SF509

Medical Record - Progress Report

07/1991

SF510

Medical Record - Nursing Notes

03/2000

SF511

Vital Signs Record

07/1995

SF513

Medical Record - Consultation Sheet

04/1998

SF515

Medical Record - Tissue Examination

08/1997

SF518

Medical Record - Blood or Blood Component Transfusion

09/1992

SF519B

Radiologic Consultation Request/Report (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)

08/1983

SF522

Medical Record - Request for Administration of Anesthesia and Performance of Operations and Other

Obsolete

SF523

Medical Record - Authorization for Autopsy

12/1980

SF523A

Disposition of Body

12/1993

SF526

Medical Record - Interstitial/Intercavitary Therapy

02/1995

SF527

Medical Record - Group Muscle Strength, Joint R.O.M. Girth and Length Measurements

09/1994

SF531

Medical Record - Anatomical Figure

06/1995

SF533

Medical Record - Prenatal and Pregnancy

12/1999

SF536

Medical Record - Pediatric Nursing Notes

02/1995

SF541

Medical Record - Gynecologic Cytology

11/1977

SF550

Medical Record - Urinalysis

04/1977

SF551

Medical Record - Serology

06/1977

SF557

Medical Record - Miscellaneous

03/1977

SF558

Medical Record - Emergency Care and Treatment

09/1996

SF559

Medical Record - Allergen Extract Prescription - New and Refill

04/1994

SF600

Medical Record - Chronological Record of Medical Care

06/1997

SF601

Immunization Record

10/1975

SF602

Medical Record - Serology Record

08/1998

SF603

Medical Record - Dental

10/1975

SF603A

Medical Record - Dental - Continuation

11/2002

Department of Veterans Affairs VAMC MEMORANDUM 658-OIT-01 VA Medical Center May 24, 2018 Salem, VA 24153 Medical Center Memorandum Policy

CODE 10 – COMPUTER SYSTEM DOWNTIME

PURPOSE: The purpose of this policy is to establish a code to be used in the event of downtime for the VA computer system(s) affecting Salem users.

POLICY: In order to inform hospital staff that the computer system(s) has incurred a downtime event and is temporarily unavailable, an overhead announcement of “CODE 10 IS NOW IN EFFECT” will be announced three times in succession using the overhead paging system. In the event that the downtime has been isolated to a system or an estimated time of recovery has been provided, this information will be included with the announcement (e.g., “CODE 10 IS NOW IN EFFECT FOR VISTA, ESTIMATED TIME 2 HOURS.”) In the event that a recovery time has not been established, Code 10 updates will be provided every 30 minutes.

RESPONSIBILITIES: Announcements can only be requested by Authorized employees designated by the Facility Chief Information Officer (FCIO)(Appendix A).

PROCEDURE: Once the system(s) is operational, authorized personnel will cancel the Code 10 and an announcement will be made using the overhead paging system that the “CODE 10 HAS BEEN CANCELLED”.

GUIDELINES:

Unscheduled Downtime is defined as any instance in which the computer system(s) experiences problems without prior indication and repairs are necessary.

Scheduled Downtime is defined as any instance in which the computer system(s) requires updates and maintenance and prior approval has been granted.

ADPACS should inform staff that the computer system(s) is unavailable and contingency plans should be utilized.

Users should not attempt to access the computer system(s) until the “CODE 10 HAS BEEN CANCELLED” announcement is made on the overhead paging system.

Notification is required whether scheduled or unscheduled downtime occurs. An Automated Notification Reporting must be submitted for the affected system(s) immediately. An IT Monitor Downtime report must be submitted after affected system(s) has been restored. These reports will be submitted via weblink or telephone by the system owner/manager.

Contingency Plan Testing/Review is an annual requirement for the Service/Service Lines. Downtime may be used to meet this requirement and Appendix E of the Contingency Plan must be submitted to OIT at the conclusion of the event.

6. FOLLOW-UP RESPONSIBILITY: Facility Chief Information Officer (FCIO).

7. REFERENCES: Automated Information Systems Guide, dated December 2009.

8. RESCISSION: VAMC Memorandum 658-OIT-01, CODE 10, dated January 21, 2011.

9. EXPIRATION: May 24, 2021

Rebecca J. Stackhouse, CTRS, FACHE Medical Center Director

Attachment

The following Information Management Service staff is authorized to request a Code 10 announcement be made:

James Knox, Area Manager Paul McAnnally, IT Supervisor Steve Poole, Lead IT Specialist Brian Campbell, CAC

CODE 10 – COMPUTER SYSTEM DOWNTIME

1. PURPOSE: The purpose of this policy is to establish a code to be used in the event of downtime for the VA computer system(s) affecting Salem users.

2. POLICY: In order to inform hospital staff that the computer system(s) has incurred a downtime event and is temporarily unavailable, an overhead announcement of “CODE 10 IS NOW IN EFFECT” will be announced three times in succession using the overhea...

3. RESPONSIBILITIES: Announcements can only be requested by Authorized employees designated by the Facility Chief Information Officer (FCIO)(Appendix A).

4. PROCEDURE: Once the system(s) is operational, authorized personnel will cancel the Code 10 and an announcement will be made using the overhead paging system that the “CODE 10 HAS BEEN CANCELLED”.

5. GUIDELINES:

a) Unscheduled Downtime is defined as any instance in which the computer system(s) experiences problems without prior indication and repairs are necessary.

b) Scheduled Downtime is defined as any instance in which the computer system(s) requires updates and maintenance and prior approval has been granted.

c) ADPACS should inform staff that the computer system(s) is unavailable and contingency plans should be utilized.

d) Users should not attempt to access the computer system(s) until the “CODE 10 HAS BEEN CANCELLED” announcement is made on the overhead paging system.

e) Notification is required whether scheduled or unscheduled downtime occurs. An Automated Notification Reporting must be submitted for the affected system(s) immediately. An IT Monitor Downtime report must be submitted after affected system(s) has ...

f) Contingency Plan Testing/Review is an annual requirement for the Service/Service Lines. Downtime may be used to meet this requirement and Appendix E of the Contingency Plan must be submitted to OIT at the conclusion of the event.

(3) For short duration code 10s, non-essential and critical treatment records on inpatient wards will be filed in the active, inpatient chart and scanned upon discharge per existing policy. For Code 10s scheduled or anticipated to exceed 24 hours, nursing should enter a “computer downtime” note in advance, if possible, for each admitted patient and critical/essential treatment records for the duration of the code 10 will be scanned to that note. Emergency Department staff must enter the downtime note for each patient post event for scanning of those ER/ED records generated during the code 10. Paper admission databases will generally be scanned post event to the computer downtime note.

(4) nurses must also enter a “computer downtime” note for each patient assigned to them during such times. All individual patient treatment records not entered in to CPRS, excluding admission databases, will be arranged in proper filing sequence and scanned as a package to the respective nursing computer downtime note by HAS/HIMS. Note: it is advisable that this computer downtime note be written in advance shortly before the outage.

(5) In the event of impending or imminent natural or physical disasters such as a fire, tornado, etc., the HIMS scanning operations center will secure all un-scanned records and treat them as “vital records” until such a time it is safe to resume scanning. The chief, HIMS will be so informed. The Chief, HIMS will determine whether a security measure for inpatient stay records and other areas is prudent.

From: Divers, Jennifer J. SAMVAMC <JENNIFER.DIVERS@va.gov> Sent: Thursday, February 11, 2021 8:44 PM To: Kendrick, Tammy R SAMVAMC <tammy.kendrick1@va.gov> Subject: Downtime procedures

Tammy

Is there a document that covers downtime procedures? I am hunting for something to include with the new contract solicitations. I have historically never known of a “guide” – the CBOCs wouldn’t have contingency computers, so is there anything that says they go to paper documentation and is there any form or something along those lines they are to document on?

I know it’s a crazy question 5 years into a VA career, but I’ve never seen it…. Or I had seen it, it must have gotten knocked out of my brain a few years ago.

Please let me know!

Thank ya!

Jennifer Divers Administrative Officer, Primary Care Service Bldg 8, Room 116b Extension 2645

“Change equals self-improvement. Push yourself to places you haven’t been before.”

Pat Summitt