D.26 658-136-30 - Management of Electronic Health Records Document Scanning.pdf

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

MANAGEMENT OF ELECTRONIC HEALTH RECORD DOCUMENT SCANNING

PURPOSE: To establish a policy and set forth procedures for the document imaging (scanning) of patient treatment documents into the Computerized Patient Record System (CPRS). It is not intended to provide central reference to all policies and procedures, but rather to establish a basic framework for scanning operations and functional management of scanning processes.

POLICY:

a. Only documents which cannot be retrieved through any other remote electronic means can be considered appropriate for scanning.

b. Only documents on approved forms will be placed in the patient’s electronic health record (EHR) in accordance with medical center memorandum 658-136-03, “the consolidated health record (CHR),” and dated March 15, 2011.

c. Appropriate medical documents originating from within the Salem VA Medical Center that cannot be accessed through CPRS should be scanned and indexed to a progress note with an annotation regarding a description of the referenced document and a statement to see VistA Imaging. Example: “see scanned sleep study dated xx-xx-xx in VistA imaging.” These documents include, but are not limited to advance directives, nursing flow sheets, informed consents, physician certification forms for DMV parking decals, disability or insurance claim forms, Family Medical and Leave Act (FMLA) paperwork, procedure records/reports, and other documents containing “wet” signatures, graphics, or other treatment records.

d. Treatment records that originate outside the Salem VA Medical Center that are ordered, requested, coordinated, or arranged by a medical care provider should be scanned into the EHR by following the procedures outlined in paragraph 4(q).

Records from other VA medical facilities that are accessible through remote access or VistA Web are not appropriate for scanning.

e. All documents containing protected health information are considered confidential in nature and will be handled in accordance with established policies and VA regulations.

f. Safeguards to prevent unauthorized access or exposure to patient-protected health information are every employee’s responsibility.

g. Obscuring of all but the patient’s last four digits on treatment records before scanning is not required, since the EHRs clearly display full social security numbers.

D.26 658-136-30 - Management of Electronic Health Records Document Scanning 36C24621R0068

Salem, VA 24153 Management of Electronic Health Records Document Scanning

h. Records will be scanned into the clinical or administrative portion of the EHR based on the document nature and content.

i. Images entered in to EHRs that expose body parts or those that could be considered nudity or of such a nature that it could lead a reasonable person to become uncomfortable, embarrassed, or in some way offended, will be shielded from chance exposure by utilizing the control image option, which will electronically place a coversheet over the image(s). This “coversheet” does not restrict access.

RESPONSIBILITIES:

a. Service/service line chiefs are responsible for designating scanning duties to non-administrative staff. Health Administration Service (HAS) and Health Information Management Service (HIMS) will provide the administrative/clerical scanning support to the maximum extent possible.

b. Supervisors of document scanners will:

(1) Ensure individualized instruction consisting of formal and one-on-one certification training is conducted by the scanning coordinator, Medical Support Assistant (MSA) lead, or supervisor.

(2) Include scanning performance measures into annual assessments for those medical support or program support assistants that conduct regular scanning duties. Will provide feedback and counseling as required outlined in paragraphs 4pp (2-3) below.

(3) Notify the scanning coordinator of scanning discrepancies or equipment issues.

(4) Ensure re-routed corrective scanning is appropriately accomplished.

(5) Request authorization for selected key program support personnel to write limited addendums and progress notes for scanning purposes only with approval from the Medical Records Committee on a case-by-case basis. Such approval will be based on mission necessity, individual familiarity with medical terminology, anatomy and physiology, scanning proficiency, and other considerations such as experience, technical abilities, and time-in-service in a medical setting.

c. HIMS Chief:

(1) Oversight and management of the Salem VA Medical Center scanning operations, delegating operational authority to the scanning coordinator as appropriate.

(2) Coordinates training with Administrative Program Application Coordinators (ADPAC) when updates and changes are made to the imaging software or CPRS.

(3) Ensures daily scanning reviews and quality assurance checks are performed and governed by the scanning coordinator.

(4) Reports the tracking of issues, trends, progress, and results to the Medical Records Committee and other offices as requested.

(5) Oversees performance improvement processes aimed at reducing or eliminating scanning errors and the advancement of electronic imaging initiatives or action plans.

(6) Requests VistA Imaging MAGCAP activation keys for trained employees.

d. Scanning Coordinator:

(1) Performs operational and management support including systems analysis for the HIMS Chief on scanning operations, process improvements, technology utilization and maximization, and instructional systems development services.

(2) Reports the tracking of issues, trends, and results, with statistical data analysis.

(3) Establishes a reliable internal records storage and retrieval system conforming to National Archives and Records Administration (NARA) and records maintenance and disposition policies as they relate to scanned records destruction authorization.

(4) Facilitates and arranges adoption or inclusion of new documents into the scanning process. Devises, submits, and catalogs appropriate scanning pathway indices for documents approved for scanning.

(5) Performs suitability reviews of records received and identifies those candidate documents for template creation.

(6) Provides training to Salem VA Medical Center staff on navigation and use of VistA Imaging software capabilities.

(7) Determines most suitable means to capture data when image clarity or quality is questionable, or where established guidelines do not exist.

(8) Authorized to sign document destruction forms and certificates.

(9) Watermarks rescinded advance directives and is authorized to place controlled image coversheets on images deemed appropriate to shield.

(10) Authorized to write administrative progress notes and addendums for scanning or administrative purposes to ensure clarity and connectivity between the notes and documents scanned.

e. Staff assigned scanning duties:

(1) Perform centralized and decentralized scanning, employing the general procedures outlined in paragraph 4. HAS and HIMS assumes the majority of scanning duties except in critical care, CBOC, and specialty areas with MSAs or where it is more expeditious or prudent to mission accomplishment to have non-administrative staff perform limited, specific scanning duties unique to the work setting.

(2) Ensure each document is authenticated with Veteran’s full name and at least one other form of positive identification such as full social security number or date of birth. Scanning personnel will be responsible for annotating any verifiable missing patient identification as appropriate. Only the last four digits should be used on patient treatment records to the maximum extent possible unless the entire SSN is necessary to ensure positive, 100% patient identification.

(3) Responsible for quality checking each document page scanned before saving. Will rotate all pages that are upside down or sideways and reduce blank pages when possible.

(4) Mark and identify blank pages by neatly and boldly writing “blank” in the center of the page. Blank page skipping technology will be used to the maximum extent possible. Individual scanners are still responsible for ensuring all pages are correctly scanned before saving.

(5) Follow established scanning procedures when entering documents into EHRs/CPRS.

(6) Notify the Scanning Coordinator of any issues concerning the process including but not limited to, incidents of misidentification, inaccurate scanning, or image quality/clarity.

(7) Will place scanned documents in the designated collection area.

(8) Must not change scanner settings without approval from the Scanning Coordinator.

ACTION:

a. Documents that meet scanning criteria will generally be handled in the clinics, treatment areas, or inpatient wards where the documents are generated. All others will be processed in the HIMS scanning operations center.

b. Outside medical documents received via mail that meet scanning criteria outlined on the approved list for outside medical record scanning (Appendix A) will be handled by the HIMS scanning operations center.

c. Scanned documents shall be marked as “SCANNED” preferably in red ink.

d. Documents must not be marked prior to scanning to prevent compromise of critical information.

e. Promptly notify the Scanning Coordinator of scanning errors or conflicts.

f. Documents to be scanned will be evaluated for suitability to convert to electronic template formats.

g. Documents scanned to an EHR will be either a clinical or administrative document.

(1) Clinical documents pertain to the on-going care and treatment of the patient and include, but are not limited to, progress notes, lab results, surgical/invasive procedure documents, imaging, outside source documents, community care records, etc. Only those clinical records that pertain to the care and treatment should be included in this record.

Determination for questionable items will be resolved by the HIMS Chief.

(2) Administrative documents pertain to non-clinical records such as Power of Attorney, means tests, physician correspondence, reports of contact, etc.

(3) Determinations for questionable items will be resolved by the HIMS Chief.

h. Inpatient treatment stay records will be scanned after discharge as complete packets for the entire duration of the admission except for wards 4H, 4J, and ICU, where critical care daily telemetry/EKG strips will be scanned daily to the appropriate EKG note. The scanner is responsible for collecting all loose records, organizing them in correct chronological sequence, and ensuring single-sided documents mixed with double-sided are taped back-to-back or the electronic skip blank pages’ option is activated on the scanning device.

i. Multi-page documents must contain personally identifiable information (PII) on each page unless the pages are consecutively numbered. Sedation/post sedation or anesthesia EKG telemetry strips must contain PII on each strip. Strips cut and pasted for scanning purposes need not each contain PII on each segment provided they are sequentially numbered.

j. Printed inpatient telemetry recordings must each contain PII. Pages must be in chronological order and in proper page sequence before scanning.

k. Documents/pages that are illegible or of poor quality or clarity, particularly faxed copies, must either be replaced with a better copy or marked with either a stamp or a neatly printed notation that indicates “poor quality original.” Person making such entry should also include his/her service line and personal initials.

l. Color pictures or images must each contain PII. It is necessary when taking pictures using a device that does not automatically embed PII to write the patient’s full name, SSN, date of birth, the procedure/event, and date on an index card, then take a picture of this card as the first and last image. Name labels of any sort are suitable to identify the patient when taking pictures of body parts. Images imported from systems that require individual patient authentication before use need not contain PII such as dental x-rays or radiological CT images.

m. documents printed from VistA Imaging must not be sent back for rescanning.

Care must be taken to identify the imaging header printed along the top of each page indicating the document(s) has/have already been scanned.

n. Other VAMC records will not normally be scanned except in rate, extenuating circumstances with prior approval of the Chief, HIMS.

o. Records sent for scanning must not be highlighted using pink, blue, or red markers because they obscure the information when scanned. Only yellow and green highlighters should be used.

p. To ensure universal precautions and infectious disease mitigation, the following procedures will be followed when handling blood or bodily fluid-contaminated documents:

(1) Where possible, documents will be placed inside a clear, plastic, zip-lock bag with the patient identifying information facing outward. If no clear, plastic bag is available, at a minimum, two layers of clear tape will be affixed over the contaminated region with a minimum of one inch overlap surrounding the outer perimeter of the contaminated area. The document or plastic covering must also be labelled “bio-hazard”

(2) The responsible party will annotate on the document or the plastic container that the document(s) have been exposed/contaminated by blood or bodily fluid to alert all other handlers.

(3) Use of alcohol or other disinfectant on the document(s) is discouraged to prevent the compromise of medical information. If any clinical information is illegible due to the contamination, the document(s) must be properly amended/corrected to reflect the actions because of the compromised information.

(4) Scanning personnel will wear appropriate protective gloves when handling the document(s) during scanning and will immediately sanitize the scanning device and areas that encountered the affected document(s).

Gloves will be properly removed and disposed of once handling and sanitation is complete.

q. Non-VA outside medical records (OMR)/external source documents may be maintained as part of a patient’s record in accordance with VHA handbook 1907.1.

r. OMRs supplied by the patient, a community care facility, or delivered to the Salem VA Medical Center that are on the approved list (Appendix A) and meet the eligibility criteria specified should generally not exceed 10 pages per category unless justified and approved by the HIMS Chief. The following OMR scanning procedure will be adhered to:

OMRs received by HIMS, regardless of delivery mode that do not have an outside medical record progress note, will be routed to the patient’s primary care provider for review.

s. Care provider(s)/physicians must first determine which documents are vitally pertinent and necessary for present or continued care which meet eligibility criteria detailed in Appendix A. Documents not identified as necessary, suitable, or are not appropriate for scanning must be shredded or given back to the Veteran. All external source, non-VA health records, except non-VA purchase care records, must be first reviewed by the practitioner. The practitioner will properly complete and sign the nationally and locally approved “Request to Scan Non-VA Documents” form (see Appendix B). Note: this request form is identical and mirrors the actual progress note so care must be taken to ensure the form is completed properly which also includes identifying the origin from where the records came, the reviewing clinician’s printed name and location and the reviewer’s signature and date signed as well as PII in the corresponding area. This completed form will serve as the required cover sheet in accordance with VHA

Handbook 1907.07. Clinical or section local policy will dictate who will then enter the appropriate outside medical records progress note with associated indexing identified to match those selected on the request. At his/her discretion, the Scanning Coordinator or designee may return the records to sender for completion of the required request form. Nursing and administrative support staff must not enter an outside medical record progress note absent the practitioners properly completed request form.

t. for Veterans admitted to a ward, the resident physician will screen the records for criteria compliance, properly complete the request form, enter the outside medical record progress note in CPRS and ensure the ward medical support assistant receives the documents in a timely manner for scanning into the Veteran’s EHR.

u. if a Veteran sends attachments (documents) via secure messaging to their respective care givers, these attachments will be treated like any other outside source medical record and will be submitted to HIMS for scanning. The caregiver must print the document, review it for accuracy, completeness, and authentication before entering the OMR note in CPRS and forwarding to scanning.

v. Non-VA prescriptions should not be scanned into VistA Imaging that are not being filled at the VA unless there is a specific progress note entry addressing the clinical necessity of maintaining an outside prescription on record. In lieu of scanning any outside prescription, the caregiver should update the patient’s medication list in CPRS.

w. non-VA anti-coagulation lab results received by the main hospital will be scanned to the pharmacy anti-coagulation note. Community Based Outreach Clinics will link their respective lab results to the PCT warfarin clinic note. These lab results will be indexed in VistA Imaging as “non-VA anti-coagulation lab results.”

DOD/military treatment records will not normally be scanned, and then only for specifically identified sections directly pertaining to on-going treatment(s) following the OMR policy outlined in paragraph 4q above.

x. A summary progress note may also be written by the care provider after a review of the external source documents in lieu of scanning.

y. Non-VA purchased care (fee) records must be entered in to the veteran’s EHR as soon as possible to ensure continuity of care.

z. All administrative and clinical information pertaining to non-VA purchased care must be maintained in the Veteran’s consolidated health record to support decisions to approve or deny claims except for the actual claim forms that are retrievable from the fee basis claims system and not considered clinical documents. They should not be scanned into VistA Imaging.

aa. The VISN 6 Centralized Business Office (CBO) will be responsible for entering all approved inpatient and emergency room treatment records into the national fee basis computer system and importing same into VistA imaging from the system document manager record storage system.

bb. Outpatient non-VA care records received from the CBO will either be forwarded to HAS NVCC or will be scanned under the VistA imaging clinical association which will not require linkage to a progress note or consult, stamped, and forwarded to the primary care provider. Fee records processed by the HAS Fee Unit must be linked to the standard, nationally approved non-VA care progress note.

cc. All OMRS must be authenticated by the originating provider which may include a written or electronic signature or initials. If unsigned documents are received, every attempt must be made to obtain the non-VA care provider’s signature. If still unsuccessful, a progress note in lieu of scanning the documents is appropriate.

dd. Draft, unconfirmed, or unverified documents will not be scanned into Veteran EHRs.

ee. Outside electronic document and image guidance:

(1) Accepting, using, and managing electronic health records received or required in an electronic format (primarily CD-ROM media) will follow the VHA health information management advisory council practice brief #6, dated July 2005.

(2) as with paper documents, the health care provider(s) must first review the electronic material to determine if inclusion into the patient’s health record is warranted following procedures in paragraph 4q in accordance with VHA Handbooks 1907.1 and 1605.1. The provider is ultimately responsible as to whether the image(s) is/are of diagnostic quality. The inclusion of outside source radiology records into Veteran’s EHRs will be on exceptional and definitive necessity cases only and not as a matter of practice. Justification for inclusion is the care provider’s responsibility.

(3) All media, electronic files, and programs shall be virus scanned prior to use (in accordance with VA Handbook 6210, “VA virus control procedures”.

Any virus detection must be immediately reported to both OI&T and the information security officer and any use of the media terminated until released by OI&T or the ISO.

(4) If it is determined that the information presented in the media has the capability of being altered or edited, the provider should be advised as to the potential unreliability of the data and should not be stored in VistA/CPRS or the Veteran’s consolidated health record.

(5) No electronic imaging will be entered without an accompanying study or written case report to link the images to.

(6) Provider is responsible for submitting an electronic CPRS outside radiology consult request along with the paper report to radiology and the disk to the radiology department for uploading. The outside medical record note must not be used for outside records in electronic formats.

(7) Only trained and authorized personnel will be permitted to upload electronic media into VistA/CPRS.

ff. Advance Directives (ADs) and Powers of Attorney (POAs):

(1) Advance directives can only be scanned to “advance directive” progress notes and are accessible to all care providers through VistA Imaging, whereas POAs are scanned to the patient’s administrative portion of the records. All medical clerks and admissions office staff have administrative record privileges if a special need to access a POA arises.

(2) Only the most recent AD and/or POA on file will be considered current.

It is the patient’s responsibility to provide current or updated copies.

(3) General Power of Attorneys (GPOAs) normally do not address medical or living will provision; only financial or personal affairs and property rights related matters and must not be scanned as advance directives. It is the responsibility of the receiver to determine the “classification” of a POA as either a POA or advance directive based on the wording and content therein. Any POAs that contain any measure of a medical or living will provision will be treated and scanned as an advance directive as well as a POA. Means tests signed by someone other than the Veteran should be scanned with the POA attached to prevent rejection by the Health Eligibility Center, unless the POA is already scanned and accessible in VistA Imaging.

(4) ADs must not be scanned to social work advance directive discussion notes

(5) State Authorized Portable Orders (SAPOs) such as the Virginia Durable Do Not Resuscitate (DDNR) will be scanned in accordance with VHA Handbook 1004.04. Care providers must write an “out-of-hospital order” note indicating that the Veteran has a Durable DNR scanned into the EHR.

The inpatient DNR order is not appropriate for SAPOs per the above cited VHA Handbook. Scanning Coordinator is authorized to write the out-of-hospital order notes for administrative scanning purposes only for DDNRs.

gg. The Scanning Coordinator and the Chief, HIMS are authorized to change advance directive note titles to “rescinded advance directive” for those that have a scanned advance directive linked to it when a Veteran rescinds, modifies, or in some way changes the document or generates a new one. This note title change will automatically place a watermark on the rescinded AD. The Scanning Coordinator will quality check and review 100% of all scanned ADs daily utilizing the daily QI report and take appropriate actions on those that have previous ADs scanned into VistA Imaging to ensure it is watermarked. The person completing the new ad progress note should also make an addendum entry to the previous AD note indicating the revocation or rescinding of that referenced AD.

hh. for those ADs that are replacing a previous version scanned by another VAMC, the respective Chief, HIMS at the other facility should be contacted to the maximum extent possible to alert them of a rescinded AD scanned by their facility so that they may initiate the watermarking.

ii. VHA Handbook 1004.2 stipulates Veterans can have both a VA and non-VA state version advance directive in their VHA electronic health records. VA advance directives will be indexed with the image description as “VHA advance directive” whereas non-VA state versions will be indexed as “non-VA state advance directive.” Previously scanned advance directives will have the image description changed accordingly as circumstances, time, and identification permit.

jj. VHA Handbook 1004.2 para 9a; page 9 requires if a delegated PACT member completes a new AD or updates an existing advance directive, the member must discuss their review with the primary care provider and other PACT mem as appropriate. Advance directive progress notes written by anyone other than the primary care provider will include the PCP as an additional signer to fulfill the VHA handbook guideline above.

kk. Consents:

(1) IMED consents are mandated to be used wherever and whenever available.

(2) All consents captured with “wet signatures” must be scanned. For consents generated on inpatient wards for miscellaneous events such as blood transfusions, tube insertions, etc., they will be kept with the inpatient record packets.

(3) Care providers must ensure consents are properly completed including dates, individual identifying information, procedure description, or intended purposes, or other appropriate information.

(4) Improperly completed consents must be corrected before scanning.

ll. Quality control:

(1) Errors will be closely tracked and monitored for trends.

(2) Scanning errors are classified as either “major-significant” or “non-significant”.

(3) “Major-Significant” errors potentially pose an imminent and serious issue should the document be needed, which could adversely impact patient safety, treatment, diagnosis, or compromise the integrity of the EHR.

Examples of “major” errors include, but are not limited to documents scanned to the wrong patient records, wrong case numbers, progress notes, or conflicts with names, dates, or titles or scanned using the incorrect indexing settings and/or image description, which could significantly impact user ease of access.

(4) All significant errors must be corrected. Other errors will be corrected to the maximum extent possible. Facility image quality standard is set at 97%, allowing no more than a 3% error rate.

(5) Poor-quality documents that cannot be improved using scanner settings will be so annotated in accordance with paragraph 4k above. It is the responsibility of the receiver/requestor of the information to obtain a better quality or make appropriate notations on the document or in the respective progress note to ensure the relevant clinical data is evident.

(6) A quality inspection of not less than 10% of each scanner’s images will be conducted each day utilizing the daily scanning report extracted from VistA. Those images reviewed will be properly marked in VistA Imaging through the QA review tool. Certain “high-value” documents, such as surgery invasive procedure flow sheets, ADs, and others deemed appropriate by the Scanning Coordinator/Chief, HIMS will be 100% quality checked each day.

(7) All quality checks of scanning will encompass correct indexing and proper linkage to notes or patient records by visually checking each page prior to saving for clarity and quality of the document information, orientation of the pages being saved, ensuring all pages are in correct order/sequence, dates match, legibility of names, dates, and content, duplication of pages or images already scanned. Any other issues or suspect clarity, quality, or content will be addressed by the chief, HIMS or the scanning coordinator.

mm. Image retractions – error corrections:

(1) Images will be retracted to ensure clarity, quality, accuracy, or completeness of the medical record. Examples include, but are not limited to images entered in the wrong Veteran’s EHR, incomplete or erroneous information entered on paper records, missing pages, pages scanned in the wrong sequence, pages scanned upside down that can easily and readily be corrected, and any other discrepancy determined by the Scanning Coordinator or Chief, HIMS deemed necessary to rescan.

(2) Deletion/retraction authority and the mag delete key is restricted to the Chief, HIMS, Scanning Coordinator, and OI&T.

(3) HIMS scanning coordinator has authority to request documents be re-scanned for clarity, quality, or accuracy reasons ensuring high standards are maintained in the Veteran’s EHR. Scanning Coordinator may, at his/her discretion, return a document to be re-scanned.

(4) Corrections on the documents must be made using a single line drawn with blue or black ink through the information and the correction noted above containing the initials and date of the person making the correction.

(5) Corrections made to a scanned document must be done manually on a printed copy using the corrective procedures above then sent back to HIMS scanning operations center for re-scanning. Scanning operations center will mark through the VistA Imaging header printed at the top of each page prior to re-scanning.

(6) Retracted images by the Scanning Coordinator will be recorded on a monthly scanning deletion record and reported monthly to the Chief, HIMS.

(7) An appropriate addendum should be made to any progress note indicating retraction of a referenced image when deleted or re-scanned to another note.

(8) Images entered in to EHRs by clinical applications, such as radiology will be deleted by the designated OI&T personnel.

(9) Only those reasons listed in VistA Imaging will be recorded when retracting a scanned image. Expanded explanation on the monthly deletion report is acceptable and encouraged. Special local reasons can be requested/added through OI&T.

(10) HIMS Scanning Coordinator has the authority to request additional reasons for image deletion specific to this facility.

(11) The SAMVAMC user default setting will be programmed to not display deleted images.

nn. CBOC scanning:

(1) CBOCs that have T-1 lines can scan approved documents at their respective sites.

(2) Without T-1 lines, there is no mechanism to quality check remotely-scanned records. Other CBOCs must coordinate and forward documents wishing to be scanned to HIMS through the CBOC’s Practice Manager.

(3) CBOCs forwarding scanning requests will follow procedures herein.

(4) Concerns and scanning issues will be resolved by the Chief, HIMS or the Scanning Coordinator.

(5) Only those documents that have specific scanning buttons established at the scanning station will be scanned. All others must be forwarded to the HIMS scanning operations center.

oo. Destruction of scanned documents:

(1) Authority to destroy scanned documents prior to the 75-year period will be in accordance with record control schedule (RCS) 10-1 and the National Archives and Records Administration (NARA) guidance, which allows VA to destroy source documents after scanning, but only if record retention and retrieval requirements can be met and quality control processes are in place. Electronic images fulfill record RCS 10-1 retention requirements.

(2) A scanned image retrieval system, accountability, and organized storage structure for a period of not less than three (3) months will be established by the Chief, HIMS. The Scanning Coordinator, at the direction of the Chief, HIMS, will implement and manage this process.

(3) Scanned documents reaching the 3-month maturity date can be discarded using only approved destruction methods. Disposition records will be maintained by the scanning coordinator.

pp. Performance monitoring:

(1) Scanning competency should be added to each HAS and HIMS competency record by the supervisor for those positions assigned regular scanning duties.

(2) No more than three (3) major-significant errors as defined in paragraph 4ll (3) will be permitted during any reporting period. Other errors and actions will be addressed on a case-by-case basis generally considering the volume, complexity, frequency, and consistency during the reporting period.

Supervisor(s) shall ensure employee(s) are aware of major-significant scanning errors when reported to them and take corrective actions.

Supervisor shall conduct written counseling once employee reached a second major-significant scanning error during the reporting period.

Supervisor shall initiate a formal scanning performance improvement plan once any employee reaches the maximum allowable major-significant errors of three (3) for the duration of a reporting period.

(3) No more than five (5) indexing errors will be permitted during any calendar month and an accumulative total of 20 for the entire reporting period. An indexing error is defined as scanning a document to the wrong preset scanning button, selecting the incorrect origin, doc/image type, specialty, procedure/event, or entering the wrong image description or failing to enter the correct image description prior to saving the image(s).

The Scanning Coordinator/Chief, HIMS may, at his or her discretion generally deem sequential indexing errors of the same nature by the same scanner on the same day as a single instance rather than multiple cases.

Supervisor(s) shall conduct written counseling to employees who exceed 15 indexing errors or make more than five (5) indexing errors in two (2) consecutive months and enter employee into a scanning performance improvement plan.

(4) Because scanning operations’ diverse complexities vary widely from position to position, the Scanning Coordinator will work in close liaison with supervisors to determine when and if employment of a scanning improvement plan is warranted considering all complexity factors, environmental conditions, technology issues, training and education, or other dynamic facets of the operation.

(5) HIMS will provide reports to the medical records committee as scheduled.

(6) Individual scanners are responsible for quality checking each document page scanned before saving to ensure all pages are legible, clarity is high, and that the document is accurately linked to the correct patient record, progress note, surgical/ radiology/lab cases, etc., as appropriate.

(7) Poor quality images or erroneous scanning will be extracted from VistA Imaging Display and re-scanned after which time the previous document will be deleted.

(8) Not less than 10% of the total number of cases captured will be quality and accuracy inspected each day. The Scanning Coordinator will ensure 100% daily quality inspections of “high value” documents such as surgical and special procedure case records, advance directives, or others as deemed appropriate. New scanners’ work will be 100% checked for a minimum of 10 working days, after which time 50% for the next 10 working days, approximately 25% for another 10 days, and then roughly 10% thereafter.

(9) It is the responsibility of each CPRS and VistA Imaging user to report poor quality images or scanning errors.

(10) copies of originally scanned documents can be re-scanned where retrieval of the original is not possible or practical providing the copies are certified as a true and correct copy.

(11) Formal individualized improvement plans will be designed and facilitated by the Scanning Coordinator using instructional systems development principles and procedures complying with VA policies with AFGE union and supervisory concurrence.

(12) The VISN 6 CBO will be responsible for quality checking their own images uploaded into VistA Imaging through the Fee Basis Computer System.

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.

(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.

ATTACHMENTS:

a. 658-136-30A - Approved List for Outside Medical Record Scanning

b. 658-136-30B - Request to Scan Non-VA Medical Documents

ETHICAL DOMAIN:

a. Patient privacy and confidentiality.

b. Professionalism in patient care.

c. Ethical practice in business and management.

d. Ethical practices in government service.

e. Ethical practices in the everyday workplace.

f. Integrated ethics program https://vaww.visn6.portal2.va.gov/salem/exec/spt/658%20MCM%20Attachments/658-136-30A%20-%20Approved%20List%20for%20Outside%20Medical%20Record%20Scanning.docx https://vaww.visn6.portal2.va.gov/salem/exec/spt/658%20MCM%20Attachments/658-136-30B%20-%20Scanning%20Request%20Form.pdf

REFERENCES:

a. VHA handbook 1605.1, “Privacy and Release of Information”, dated May 17, 2006.

b. Hospital accreditation standards, the Joint Commission, current edition.

c. VHA Handbook 1907.1, “Health Information Management and Health Records”, dated September 19, 2012.

d. VHA Handbook 1004.04; “State Authorized Portable Orders (SAPO),” dated October 25, 2012.

e. E. VHA Handbook 1907.07; Management of Health Records File Room and Scanning, May 12, 2016

FOLLOW-UP RESPONSIBILITY: Chief, Health Information Management Services and Scanning Coordinator.

RECESSION: Medical Center Memorandum 658-136-30, “Document Scanning,” dated December 31, 2013

EXPIRATION: December 27, 2020

Rebecca J. Stackhouse, CTRS, FACHE Medical center director Salem VAMC