D.25 IM-32 DOCUMENTATION OF VETERAN CARE.pdf

Butler VA Health Care System Medical Center Memorandum IM-32 Butler, PA November 21, 2019

DOCUMENTATION OF VETERAN CARE (34)

I. PURPOSE: To establish a policy for the accurate and timely documentation of Veteran care information by all disciplines and completion of patient care encounter data.

II. POLICY: It is the policy of Butler VA Health Care System to provide accurate and timely documentation of Veteran care and activity. The contingency plan is initiated according to MCM IM-10 Computerized Patient Record System (CPRS). All persons with access to medical records will maintain confidentiality of Veteran information. The facility will also capture and report inpatient appointments in outpatient clinics, inpatient billable professional services, and outpatient care data to support the continuity of patient care, resource allocation, performance measurement, quality management, provider productivity, research, and third-party payer collections.

III. RESPONSIBILITY:

A. The Director, Chief of Staff, and Associate Director for Patient Care Services have the overall responsibility to assure that Veteran care is documented in accordance with established policies, standards of care, and standards of practice. They will also ensure:

1. That all clinics are using the appropriate DSS identifiers;

2. That an annual review and update of locally developed documentation templates are performed;

3. That nationally developed electronic encounter forms are reviewed and updated quarterly;

4. That all encounter check-out information is entered, transmitted, and accepted by the close-out date;

5. That clinic support staff monitor and cancel appointments and indicate “No Shows” appropriately and timely to prevent these types of appointments from appearing on the Encounter Action Required Report.

B. Veterans Health Administration (VHA), by Federal policy, must maintain complete, accurate, timely, clinically-pertinent, and readily-accessible patient records which contain sufficient recorded information to serve as a basis to plan patient care, support diagnoses, warrant treatment, measure outcomes, support education and research, facilitate VHA performance improvement processes and legal requirements.

C. Program Managers are responsible for staff compliance with the documentation policy, content, and appropriateness and ensuring that staff are aware and comply with the management of appointments specific to their service. Each program area will develop its own internal review mechanism for documentation in the medical record consistent with VHA and organizations such as The Joint Commission, The Commission

2 Medical Center Memorandum IM-32 for the Accreditation of Rehabilitation Facilities (CARF), and The College of American Pathologists (CAP).

D. The Medical Records Committee (MRC) is responsible for advising and recommending improvements regarding the documentation of Veteran care. MRC will also approve the creation of newly created, locally developed documentation templates in accordance with their established procedures.

E. The Chief, Health Information Management (HIM) or designee will review and update national encounter forms on a quarterly basis.

F. The Health Informatics Specialists (HIS) are responsible for the training of clinical and non-clinical staff, as well as contracted health care professionals in the use and functionality of the electronic medical record.

G. Supervisors are responsible to ensure staff competency in documentation and encounter completion.

H. Staff members are responsible for documentation that is inclusive of the Veteran’s assessment, plan of care, status, condition, response to interventions and/or treatment/medications, progress toward goals, education, and evaluation of care provided and to ensure the encounter is completed timely and accurately. The best practice is to document and closeout encounter at the time of resident care activity but no later than 48 hours unless otherwise specified in Attachments A, B, C, D and E.

I. Any change to documentation timeframes (Attachments A, B, C, D and E) are approved through the Director via a revision to this Medical Center Memorandum. Any change in the context of CPRS documentation is approved through the Medical Records Committee as outlined in MCM IM-21, Medical Record Review Committee.

IV. PROCEDURES:

A. Format: The SOAPIER format is the preferred method to document care.

Elements of this format are utilized according to the established guidelines of this policy.

All or part of the SOAPIER acronym may be used.

1. S - Subjective: What the Veteran tells the author. This can be a direct quote.

2. O - Objective: Veteran's clinical signs or factual data gathered by observation of the Veteran.

3. A - Assessment: Conclusion reached by the professional staff about the Veteran's condition.

4. P - Plan of Care: What is planned concerning the treatment of the Veterans problems now, or in the future.

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5. I - Intervention: What is done to, for, or with the Veteran/significant other to resolve any identified problems/needs.

6. E - Evaluation: Veteran's response to care provided and the outcome of the care.

7. R – Revision: Change to the plan of care as the result of a reassessment.

B. Documentation:

1. Documents are legible, pertinent, accurate, and include only relevant information.

2. Documentation is entered at sufficient intervals and in detail necessary to accurately record the Veteran’s clinical progress and medical status by utilizing CPRS.

Specific documentation requirements are outlined in Attachment A, B, C, and D.

3. Approved abbreviations, according to Medical Center Memorandum IM-16 Approved Abbreviations and Symbols for Medical Records, are used when documenting in CPRS.

4. Contingency Plan when CPRS is not available:

a. All manually maintained documentation is completed on approved medical record forms.

b. Approved forms will contain the date and time the note is written.

c. Errors in manual charting are crossed out with a single line and the word error written above it with the date and the writer's initials.

d. Errors in manual charting will not be erased or eradicated.

e. Full signature and title are written immediately following the ending of the manual document.

f. No blank lines are left between entries.

g. Late entries are written on the progress note form with the date and time of the note in real time. The note must be designated as a late entry and the reason for the late entry must be documented. A late entry is considered documentation greater than 48 hours after resident care activity unless timeframes otherwise specified in Attachment A, B, C, and D.

5. An addendum is made in CPRS when a supplemental note is needed to add meaning or explain the previous note. This note is labeled "Addendum".

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6. Consults are completed in CPRS by the point of contact as indicated by Program Line process.

7. Late entries are entered in CPRS with the date and time of the note in real time.

The note must be designated as a late entry and the reason for the late entry must be documented. A late entry is considered documentation greater than 48 hours after resident care activity unless timeframes otherwise specify in Attachment A, B, C, and D.

8. Errors in CPRS are documented according to Medical Center Memorandum IM-10 Computerized Patient Medical Record System (CPRS). Erroneous document entries are corrected by entering an addendum in CPRS to reflect the indicated document is in error. A VistA e-mail message is sent to G.Erroneous Mailgroup for title change to “erroneous note”.

9. Screening, Assessment, and Re-Assessment:

a. Long Term Care Residents in the Community Living Center are assessed upon admission and according to the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) requirements. The initial assessment is completed upon admission and includes: current diagnosis, medications, and treatments; physical and neuropsychiatric status, communication status, functional status, rehabilitation potential, nutrition/hydration status, oral health, psychosocial status, spiritual needs, cultural and ethnic factors that may influence care; and the resident’s personal preferences.

b. Veterans in the Home Based Primary Care (HBPC) Program are assessed upon admission and annually. The assessment, based on the Veteran’s condition and needs, includes pertinent diagnoses, physical findings and history, functional status, psychosocial status, cultural or religious practices that may affect, care that the family or support system is able to provide, education needs, nutritional status, medication history and current use, and equipment needed in the home.

c. Veterans enrolled in the outpatient Behavioral Health Program are screened for nutritional status, legal status, and vocational status. Veterans for whom a more in-depth assessment is indicated are assessed by the clinician or referred for further treatment.

d. Veterans in the Residential Rehabilitation Treatment Program are assessed upon admission. The assessment, relevant to care, treatment and/or services, will include living situation, leisure and recreational interests, religion or spiritual orientation, cultural preferences, military history, financial issues, language preference, and ability to self care including medication administration.

e. Veterans in the Ambulatory Care Program are assessed by the provider at each scheduled provider visit and as needed. The assessment, which is based on the condition and needs of the Veteran, includes the physical, psychological, and social status, nutrition, hydration, and functional status.

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f. Veterans in all programs are screened, assessed, and reassessed as indicated in MCM PC-39, General Pain Management Program.

g. Veterans in ambulatory care, home care, and behavioral health are screened for various health factors. The clinical reminder serves as an alert to notify staff as each screening is due. Positive screenings require a more in-depth assessment by the clinician.

10. Veteran Education:

a. Each program (Long Term Care, Home Based Primary Care, Behavioral Health, and Ambulatory Care) will provide education and training based on each Veteran’s needs and abilities.

b. The Education Evaluation will determine the education and training needs of the Veteran and will include an evaluation of the Veterans understanding of the education and training provided.

11. Timeframes: Program-specific documentation requirements can be found in Attachments A, B, C, and D.

a. Workload data must be captured through electronic means, including electronic encounter forms, event capture, and the laboratory, radiology, and surgery packages.

b. National electronic encounter forms are reviewed and updated quarterly for the International Classification of Diseases, 10th Revision (ICD-10) update and Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) updates.

c. Electronic encounter form data entry is to be entered by the providers on the same date as the encounter.

d. The Clinic Management Committee (CMC) will set up and maintain clinics assuring the accurate Decision Support System (DSS) identifiers are assigned. Clinic set-up and DSS identifiers are confirmed by the CMC before a clinic is activated.

e. Inpatient and outpatient encounter data is transmitted to the National Patient Care Database (NPCD) at the Austin Automation Center (ACC), Austin, TX, and accepted to meet the close out date.

V. REFERENCES:

The Joint Commission Comprehensive Accreditation Manual, 2019 MCM IM-16, Approved Abbreviations and Symbols for Medical Records MCM IM-10, Computerized Patient Record System MCM IM-21, Medical Record Review Committee MCM PC-39, General Pain Management Program

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MCM PC-111 Assessment, Prevention and Treatment of Pressure Ulcers VHA Handbook 1907.01 Health Information Management and Health Records

VI. RESCISSION: Medical Center Memorandum IM-32, dated March 22, 2018

SHARON COYLE, MSN, RN, MBA

Interim Director

Attachments: A, B, C, D, E

(Automatic Review Date: November 21, 2022)

ATTACHMENT A

LONG TERM CARE DOCUMENTATION REQUIREMENTS

(Entered and signed within 48 hours of encounter unless otherwise indicated)

DISCIPLINE DOCUMENT TIMEFRAME

Chaplain Admission Assessment -

LTC

Within 14 days of admission

Reassessment - LTC Every 90 days

Admission Assessment - Hospice, Palliative Care

Within 24 hours of admission

Reassessment - Hospice, Palliative Care

Every 14 days

Progress Note With any change in condition/in response to care/treatment

Palliative Care Note (Hospice)

With any change in condition/in response to care/treatment

Bereavement Telephone Note

Within 14 days of death

Registered Dietitian Admission Assessment Within 7 days of admission

Progress Note (Level IV) Monthly

Progress Note (Level I, II, III)

Quarterly

Palliative Care Note (Hospice)

With any change in condition/in response to care/treatment

Plan of Care By day 21 of admission

Nursing Admission Assessment Within 8 hours of admission

Progress Note Daily for 3 days after admission

Progress Note With any change in condition/in response to care/treatment

Progress Note (fall) Each shift for 3 days after fall

Palliative Care Note (Hospice)

With any change in condition/in response to care/treatment

Death Note (Support) All deaths

Braden Skin Assessment On admission/weekly

Attachment A

Monthly Note Monthly on all residents

Plan of Care (interim) Within 8 hours of admission

Plan of Care (complete) By day 21 of admission

Education Assessment Within 8 hours of admission

Pain Assessment Within 8 hours of admission/when pain is identified

Pain Reassessment Weekly if pain is a problem

Discharge Summary On day of discharge

Restorative Nursing Assessment Within 72 hours of admission

Reassessment Quarterly

Plan of Care By day 21 of admission

Physical Medicine and Rehabilitation Service

(PT, KT, OT, ST)

Functional Assessment/Nursing Admission Safety Assessment

Within 4 hours of admission (Off tour admissions: PCC/Charge RN completes and therapy reviews next business day.

Progress Note - LTC patients

With each visit (in response to care/treatment)

Progress Note - CIIRP Patients

Daily (in response to care/treatment)

Recreation Therapy Life History By day 7 of admission

Recreation Assessment By day 7 of admission

Plan of care By day 21 of admission

Progress Notes - LTC Patients

Quarterly

Pharmacy Initial Assessment Within 72 hours of

Medication Review Every 30 days

Plan of Care (residents prescribed antipsychotics)

By day 21

Palliative Care Note (Hospice)

With each visit (in

Social Work Admission Assessment By day 14 of admission

Reassessment Annually

Attachment A

Progress Notes With each visit in response to care/treatment

Education on Advance Directives

Upon admission/annually

Advance Directive Reviewed quarterly at IDT

Progress Note Quarterly

Plan of Care By day 21 of admission

Palliative Care Note (Hospice)

With each visit (in

Dental Oral Health Assessment By day 14 of admission

Medical Provider History and Physical – Within 72 hrs of admission

Medication Reconciliation Within 48 hours of admission

Progress Note In response to medical care/treatment

Progress Note Every 30 days

Palliative Care Note (Hospice)

With any change in condition/in response to care/treatment

Discharge Summary Within 72 hours of discharge

Death Note (Base) All deaths

ATTACHMENT B

AMBULATORY CARE DOCUMENTATION REQUIREMENTS

(Entered and signed within 2 business days of encounter unless otherwise indicated)

Health Technicians Women’s Health Prevention Note

With each visit

Men’s Health Prevention Note With each visit

Clinical Reminders As due at each visit

Education Evaluation With initial visit or change in condition

Pain Screening With each Visit

Nursing Quick Check Notes In response to

Telephone Glucometer Blood Sugar

In response to care/treatment

Telephone Blood Pressure In response to

Medical Provider Assessment – Medication List/Reconciliation

With each visit

Progress Note With each visit

Braden Skin Assessment With initial visit/annually

Problem List/Summary By the third visit

Pain Assessment With each visit (if screening is positive)

Pain Education With each visit (if screening is positive)

Pressure Ulcer risk, prevention, and treatment education

With initial visit/annually

Clinical Reminder Follow Up Assessment

For any positive clinical reminder

ATTACHMENT C

OUTPATIENT BEHAVIORAL HEALTH/SOCIAL WORK

DOCUMENTATION REQUIREMENTS

All Disciplines Treatment Plan Within 3 sessions

Nutrition Screen Annually

Progress Notes With each visit (in

HUD/VASH PROGRAM

All Disciplines Treatment Plan Within 5 sessions

Progress Notes Within 5 days of patient encounter

ICMHR-RANGE

PROGRAM

All Disciplines Treatment Plan Within 5 sessions of

Progress Notes Within 5 days of patient

VETERAN JUSTICE

OUTREACH PROGRAM

All Disciplines Progress Notes Within 5 days of patient

DOMICILIARY DOCUMENTATION REQUIREMENTS

(Entered and signed within 48 hours of encounter unless otherwise indicated)

DISCIPLINE DOCUMENT TIMEFRAME

Nursing Admission Assessment Within 24 hours of admission

Interim Plan of Care Within 24 hours of admission

Nurse Practitioner History and Physical Within 72 hours of admission

Discharge Summary Within 72 hours of discharge

Vocational Rehab Specialist

Vocational Assessment Within 5 days of admission

Psychologist Psychological Assessment Within 5 days of admission

Chaplain Spiritual Assessment Within 5 days of admission

Attachment C

Case Managers Treatment Plan Within 5 days of signed first contract

Treatment Plan Updates Every 30 days after initial treatment plan

Case Management Individual Notes

Weekly during Phase I, every 2 weeks thereafter

All Disciplines First Contract Within 5-7 days of

Progress Notes With each visit (in

ATTACHMENT D

HOME BASED PRIMARY CARE (HBPC) DOCUMENTATION REQUIREMENTS

(Entered and signed within 5 business days of encounter unless otherwise indicated)

Nursing Assessment On admission and annually

Progress Note Monthly

Treatment Plan Quarterly

Medication List With each visit in response to care/treatment

Clinical Reminder As due with each visit

Telephone Encounter In response to care/treatment

Fall Note If fall is reported at visit

Discharge Addendum On discharge

Physical Therapy Functional Status Assessment

On admission and annually

Environmental Assessment On admission and semi-annually

Progress Note With each visit in response to care/treatment

Treatment Plan Quarterly

Social Work Psychosocial Assessment On admission and annually

Caregiver Assessment Annually

Treatment Plan Quarterly

Progress Note With each visit in response

Registered Dietitian Assessment On admission and annually

Treatment Plan Quarterly

Consult With each visit in response to care/treatment

Pharmacy Treatment Plan/Medication Reconciliation

Quarterly

Attachment D

Progress Note With each visit in response

Certified Registered Nurse Practitioner and Physician Assistant

History and Physical On admission and annually

Narrative Note In response to

Treatment Plan Coordinator

Admission Evaluation On admission

Treatment Plan Summary Quarterly

Discharge Base Note On discharge

HOME TELEHEALTH DOCUMENTATION REQUIREMENTS

DISCIPLINE DOCUMENT TIMEFRAME

Nursing Continuum of Care Every six months

Education Note On admission

Emergency Management Note

Every six months

Evaluation Note Quarterly and with alerts

Treatment Plan Evaluation On Admission

Telephone Encounter With non alert issues

Discharge Note On discharge

Screening consult Initial evaluation

ADULT DAY HEALTH CARE DOCUMENTATION REQUIREMENTS

(Entered and signed with 2 business days of encounter unless otherwise indicated)

DISCIPLINE DOCUMENT TIMEFRAME

Nursing Admission Assessment Within 14 days of admission

Interdisciplinary Treatment Note

Within 21 days of admission and quarterly

ADHC note Daily

Interdisciplinary Meeting note

On discharge

Kinesiotherapy Interdisciplinary Treatment Note

Within 21 days of admission and quarterly

Progress note Daily (in response to

Attachment D

Interdisciplinary Meeting note

On discharge

ATTACHMENT E

DEFINITIONS

Action Required: This is the terminology used to indicate an encounter that is incomplete.

The provider will not receive workload credit; the facility will not receive reimbursement through Veteran Equitable Resource Allocation (VERA), the Veteran’s third-party reimbursable health insurance plan, and any first party copays the Veteran may be responsible for.

Active Problems: Problem and/or diagnosis(es) treated that relate to the encounter are required to be reported as ICD-9-CM codes for each encounter. A minimum of one is required. When more than one active problem or diagnosis is designated for an encounter, the practitioner must determine which one is the primary reason the patient sought treatment at that encounter. Additional diagnoses or conditions that were treated, evaluated, or affected the treatment of the patient during the encounter must be included as additional secondary codes. Only the codes are transmitted to NPCD. Guidelines published by the American Hospital Association, ICD-9-CM, and the National ICD-9-CM coding conventions and guidelines must be followed for ICD-9-CM code assignment.

Classification Questions: The determination of whether or not a treatment was related to an adjudicated service-connected condition or treatment of conditions related to exposure and/or experience for (Agent Orange, Ionizing Radiation, Military Sexual Trauma, Combat Veterans, or Environmental Contaminants) must be based on all conditions treated during the encounter and the entire encounter is designated service-connected or designated as being related to the special categories, if any treatment related to these conditions was provided.

Collateral Services: Collateral services are services provided to persons other than the patient as part of the patient’s care (such as family therapy). They are not to be reported separately. Collateral services provided directly to the collateral (for example, to the spouse) separate from the patient must be reported separately for the collateral, i.e., stress reduction skills.

Date and Time of Service: The actual date and time that the encounter or service was scheduled to occur. Time is a single entry indicating the time the encounter was scheduled to occur. This data element is taken from the Appointment Scheduling software. When unscheduled encounters are entered, the date and time that the encounter is entered into VistA is what is used as the encounter date and transmitted.

The date and time data elements must be identical in VistA and NPCD.

Encounter: An encounter is a professional contact between a patient and a practitioner with the primary responsibility for diagnosing, evaluating, and/or treating the patient’s condition. Encounters occur in both the outpatient and inpatient setting. Contact can include face-to-face interactions or those accomplished via telemedicine technology.

Attachment E

Occasion of Service: An “occasion of service” is a specified identifiable instance of an act of technical and/or administrative service involved in the care of a patient or consumer which is not an encounter; that is, does not include the exercise of independent medical judgment in the overall diagnosing, evaluating, and/or treating the patient’s condition.

(Note: Occasions of service replace the previously used term “ancillary services”).

Examples of “occasion of service” include Clinical laboratory tests, radiological studies, physical medicine interventions, medication administration, and vital sign monitoring.

Patient: The person receiving health care services.

Practitioner: Health care staff providing services to the patient. This includes medical staff providers, patient care services staff, and staff of all other clinical services.

Service Provided: Services provided to the patient by the practitioner must be fully supported by medical documentation. Only nationally accepted coding systems such as Current Procedural Terminology 4 (CPT-4) codes and Health Care Procedure Coding System (HCPCS) codes are to be used to reflect all services provided by applicable practitioners, including modifiers, when appropriate. Guidelines established by the American Medical Association must be followed for CPT-4 code assignment.

• The supervising or attending physician is to be listed as the primary provider for all encounters. Other providers or practitioners need to assign themselves as the secondary provider. Use of Evaluation & Management (E&M) codes require that certain criteria be met within the coding guidelines. Those practitioners licensed and privileged within the scope of their practice may limit the use of many E&M codes.

• Guidelines published by the Centers for Medicare & Medicaid Services (CMS) in general are followed for HCPCS code assignment.

• Code assignment must depict services rendered and documented. Only the provider of service should be completing the encounter. Qualified coders will edit encounters after a comprehensive review of the documentation, if applicable.

Telemedicine and/or Telehealth Services: Telemedicine is generally described as the use of communication equipment to link health care practitioners and patients in different locations. This technology is used by health care providers for many reasons, including cost efficiency, reduced transportation expenses, improved patient access to specialists and mental health providers, improved quality of care, and better communication between providers. For Veterans Health Administration purposes, a telemedicine contact between a practitioner and a patient is considered an encounter if the specific conditions are met as outlined in DSS instructions for Telemedicine.

Telephone contact: Contact between a practitioner and a patient is only considered an encounter when the telephone contact is documented and that documentation includes the appropriate elements of a face-to-face encounter, namely history and medical decision-making. Telephone encounters must be associated with a telephone clinic that

Attachment E is assigned one of the DSS telephone three-digit identifiers. Telephone encounters are to be designated as non-billable and are count clinics. (Note: “Count” refers to workload that meets the definition of an encounter or an occasion of service).

Visit: “Visit” is used for the purpose of reporting services provided to a Veteran and/or patient in a 24-hour period; for example, the visit of an outpatient to one or more clinics or units with one calendar day at the facility level, including the station number and the suffix identifiers (i.e., for facilities, visits are to be reported at the three digit station level, for visits reported; for instance, at Community Based Outpatient Clinic’s it must include the suffix).

Workload Only: Situations may exist which are workload only. That is, they meet neither the definition of an encounter nor an “occasion of service”. “Workload only” clinics within the scheduling application need to be set to non-count and non-billable. These are tracked for workload only (internal use), and are neither an encounter nor an occasion of service.