D.28- PATIENT MEDICAL RECORDS MANAGEMENT POLICY, MEDICAL RECORD STANDARDS.pdf

RECORDS MANAGEMENT POLICY

MCP 00-22

Syracuse VA Medical Center Syracuse, NY 13210

Signatory Authority:

Medical Center Director

Responsible Owner:

Records Manager

Rescinded Document:

MCM 00-22, Records Management

Policy, February 2017

Effective Date:

April 2020

Recertification Date:

April 2025

1. POLICY

Each Organizational entity shall establish and maintain an active, continuing records management program that effectively and efficiently manages federal records throughout their life cycle. This medical center policy (MCP) establishes the Syracuse VA Medical Center policy for records management program.

2. JUSTIFICATION

Title 44 of the United States Code (USC) Chapter 31, Title 36 of the Code of Federal Regulations (CFR) Chapter XII Subchapter B- “Records Management”, and VA and VHA records management policies.

3. RESPONSIBILITIES

a. Medical Center Director. The Medical Center Director is responsible for:

(1) Designating a facility Records Manager and Alternate Records Manager to coordinate and oversee the records management program. NOTE: Alternate Records Managers must be capable of taking full responsibility for managing the Records Management program in the Records Manager’s absence.

(2) Ensuring the facility is in compliance with all provisions of the VHA records management program, to include establishing a facility vital/essential records program.

(3) Provides the necessary resources (funding and personnel) to support the Record Management Program.

(4) Ensures that all record management requirements mandated by VA policy, VHA policy and other Federal legislation are met.

(5) Ensuring all service lines/departments and Community Based Outpatient Clinics (CBOCs) support the facility Records Manager in all aspects of the facility records

Attachment D.28 RFP 36C24224R0049

March 2020 MCP 00-22 management program and designate Records Liaisons to prepare and maintain the service /department/CBOC Records Inventory and File Plan.

b. Service Chiefs, Service Line Managers, Program Supervisors/Managers.

The Service Chiefs, Service Line Managers, Program Supervisors/Managers are responsible for:

(1) Appointing a Record Liaison to support the records management program.

(2) Ensures the Record Liaison collaborates with the Records Manager on all projects concerning the creation, maintenance and use, and disposition of all records.

(3) Ensures all workforce within their service/department are aware of and abide by this policy and other policies outlined in this policy.

(4) Seeking advice and assistance, as needed, from the Facility Records Manager concerning records management problems or concerns.

(5) Ensures that employees, volunteers, and contractors under their supervision, including those departing, do not remove Federal records from VHA custody and transfer Federal records in their possession to an official recordkeeping system.

c. Chief Information Officer (CIO)/Chief Office Information and Technology (OIT) or designee. The Chief Information Officer (CIO)/Chief Information and Technology (OIT) or designee is responsible for:

(1) Establishes, coordinates, and maintains automated information systems to support the Records Management program in accordance with all applicable VA and VHA regulations.

(2) Implements a program for managing electronic and audiovisual records and microfilm media in accordance with current Federal regulations.

(3) Ensures all electronic records are migrated to existing current software to ensure records are readable and usable throughout their life cycle.

(4) Coordinates with the Records Manager to provide technical advice and other assistance relative to the record management requirements for implementation of IT systems, policies and procedures.

d. Contracting Office Representative (COR). The Contracting Office Representative is responsible for:

(1) Collaborates with the Records Manager to ensure that records and information created, received, or maintained by contractors are maintained in accordance with all VA and VHA policy and procedure.

(2) Ensures that contractors are aware of, and abide by, records management procedures as stated in the contract.

(3) Ensures that current records requirements criteria are stated in the Performance Work Statement.

(4) Ensures that contract performance meets record management requirements and appropriate actions are taken to terminate the contract if such requirements are not being met as noted in the current Performance Work Statement.

e. Records Manager and/or Alternate Records Manager. The Records Manager and/or Alternate Records Manager is responsible for:

(1) Managing and coordinating a records management program for their respective organization. The program goal is to manage and safeguard federal records throughout their lifecycle (creation, maintenance, use, and disposition).

(2) Implementing policy and procedures, including facility-specific standard operating procedures, for administering the facility records management program and updating as necessary to ensure they are current, relative and comprehensive.

(3) Reviewing all existing facility policies as needed but at least annually, to ensure consistency and compliance with this policy and RCS 10-1.

(4) Completing the VA Talent Management System (TMS) course, “Records Management for Records Officers and Liaisons” annually and other required records management training as directed, in order to fulfill the annual NARA training requirement of 36 CFR 1222.24(b). NOTE: The current mandatory training is “Records Management for Records Officers and Liaisons”, TMS Item #3873736.

(5) Ensuring all employees complete the VA Talent Management System (TMS) course 10176, “Privacy and Information Security Awareness and Rules of Behavior” in order to fulfill the annual NARA training requirement of 36 CFR 1222.24(b)

(6) Implementing approved records dispositions, while ensuring that no records are destroyed without proper authorization as specified in the RCS 10-1 or General Records Schedule (GRS).

(7) Systematically reviewing and updating the facility Master Records Inventory and File Plan at least annually.

(8) Contacting the VHA Records Officer when unscheduled records, regardless of medium, are discovered within the facility. Once the unscheduled record is identified, the facility Records Manager will protect the unscheduled record from destruction until a new records schedule is approved by NARA.

(9) Conducting regular internal records management reviews in accordance with VHA Directive 6300.01, Records Management Compliance Monitoring, to assist offices within the facility in implementing appropriate records management procedures.

(10) Serving as an advisor to the facility’s Continuity of Operations (COOP) team/Emergency Management Team to assist in the implementation of the COOP/Emergency Management and the Essential Records program in accordance with the VA-wide program in VA Handbook 6300.2, Management of the Vital Records Program.

(11) Apprising facility leaders and managers on matters relating to records management activities and requirements and serving as the facility subject-matter expert related to records management activities and requirements.

(12) Developing records management oversight roles and communication networks with all facility service and product lines, programs, and Community Based Outpatient Clinics (CBOCs) to ensure that the records management program is carried out in accordance with this policy.

(13) Providing technical advice and training to Records Liaison(s) and facility staff on maintaining an effective records management program.

(14) Determining if permanent records are ready for transfer to NARA.

(15) Ensuring that departing employees do not remove facility records from VHA custody and that they transfer custody of the records to the appropriate employee or office prior to being cleared.

(16) Reviewing facility contracts that create, use, store, and disposition Federal records in order to ensure compliance with all records management regulations.

(17) Ensuring all inactive record storage locations meet the requirements of 36 CFR 1234, Subpart B, “Facility Standards for Records Storage Facilities.”

(18) Collaborating with the facility Privacy Officer in the identification of systems requiring a new System of Records Notification (SORN) and ensuring that the correct records disposition is used.

(19) Assisting the Office of General Counsel, facility Director and the VHA Records Officer in the execution of records litigation holds.

(20) Completing the Privacy Compliance Assurance (PCA) Facility Self-Assessment (FSA) quarterly and cooperating with PCA in audit and remediation activities, as specified by PCA.

(21) Report the loss, destruction, or damage to Federal records to the facility Director as required by 36 CFR 1230.

f. Records Liaison (RL). The Records Liaisons are responsible to the Records Manager and their supervisor for:

(1) Full implementation of the records program at their service/department level.

(2) Working in conjunction with the facility Records Manager to ensure full and proper implementation of the records management program within their respective area.

(3) Maintaining, reviewing and managing their respective service line, program offices, or CBOCs Records Inventory and File Plan and providing updates to the facility Records Manager, at least annually.

(4) Completing the VA Talent Management System (TMS) course, “Records Management for Records Officers and Liaisons” annually and other required records management training as directed (see paragraph 12.b), in order to fulfill the annual NARA training requirement of 36 CFR 1222.24(b).

(5) Promptly reporting the accidental/unauthorized destruction or catastrophic loss of facility records to their immediate supervisor and the facility Records Manager. (See 36 CFR 1230.) NOTE: Facility Records Manger should notify by phone or email the VHA Records Officer of record destruction within five (5) business days of learning of said destruction, with the exception of any destruction that has already raised public awareness (i.e. news coverage); publicized destruction notification should occur immediately or as soon as possible.

(6) Contacting the facility Records Manager when unscheduled records in any medium are discovered within the facility.

(7) Assisting the facility Records Manager with staff training related to their records management responsibilities.

(8) Conducting regular internal record reviews to ensure an effective records management program is maintained for their respective service line, program office or

CBOC.

(9) Ensuring departing employees do not remove any facility records from VHA custody and that they transfer custody of the records to appropriate employee or office, as determined by their service line, prior to being cleared.

(10) Ensuring all destruction of Federal records is documented on VA Form 7468 and provided to the Records Manager immediately upon completion.

(11) Assisting the facility Records Manager with the Essential Records program, in accordance with the VA-wide program in VA Handbook 6300.2, Management of the Vital Records Program.

(12) Assisting with the transfer of eligible records to NARA approved records storage centers.

(13) Ensuring all inactive record storage locations meet the requirements of 36 CFR 1234, Subpart B, Facility Standards for Records Storage Facilities.

g. All VHA Workforce. The VHA workforce is responsible for:

(1) Cooperating with the facility Records Manager and RL(s) in creating, maintaining, safeguarding, and disposing of federal records in accordance with the facility records management program.

(2) Completing the VA TMS course 10176, “Privacy and Information Security Awareness and Rules of Behavior” in order to fulfill the annual NARA training requirement of 36 CFR 1222.24(b).

(3) Understanding what constitutes a Federal record and applying VA, VHA, and NARA regulations and guidance to all Federal records.

(4) Ensuring Federal records in their custody are included in the service’s file plan, and that the records are maintained and disposed of in accordance with VHA RCS 10-1 or the GRS.

(5) Immediately reporting the accidental/unauthorized destruction or catastrophic loss of facility records to their immediate supervisor and their service records liaison as required by 36 CFR 1230.

(6) Ensuring proper authorization is obtained before removing records from the facility.

4. PROCEDURES

a. Records Life Cycle. The facility will manage records throughout their life cycle:

(1) Creating Federal Records

(a) The creation of Federal records shall be limited to records that are essential for administrative, legal, or fiscal purposes to include patient care functions. Examples of records include (but are not limited to): health records, medical device inspection records, accounting records, dietary records, supply orders and invoices, facility and program policies, decisions, and procedures, personnel records, contracts, project files, etc.

(b) Records shall be created in a medium and format that meets the administrative and clinical needs of the facility. Consideration must be given to the length of time the records will be maintained to ensure that the information will be accessible throughout its expected lifecycle.

(c) The records and information collected and created by personnel in the conduct of official business belong to the Federal Government and not to the employee(s) who initiated their collection or creation. Records or information collected or created by VA in any form, manual or automated, may not be disposed of (destroyed, erased, loaned, or otherwise removed from VA custody) without authorization from NARA. Until a request for disposition is approved by NARA, the records are unscheduled and shall be maintained indefinitely.

(2) Maintenance and Use of Federal Records.

(a) The records and information collected and created by VHA personnel in the conduct of official business belong to the Federal government and not to the employee who initiated their collection or creation. Legal authorization to sell, reassign to another government agency, destroy/erase, or otherwise remove records and information from VHA control must be obtained from the Archivist of the United States, NARA, via the VHA Records Officer.

(b) The maintenance and use of the record, includes functions such as filing, retrieving, use, duplication, printing, dissemination, release, and exchange of the records. Record filing, indexing and storage systems should be designed and documented to the extent appropriate and necessary to maximize the usefulness of the records and allow for ready retrieval throughout the record’s life cycle.

(c) Each series of records should have a file plan which promotes ease of access to the information as appropriate.

(d) The facility will maintain and preserve records necessary to protect the legal and financial rights of the government and of persons directly affected by its activities.

Reasonable efforts will be made to maintain records in formats or media that are reproducible for purposes of the Freedom of Information Act (FOIA). Duplicate records will be prepared only in amounts required for the efficient operations of the facility or as required by Federal regulations.

(e) Within their department and/or program, and where applicable, the Records Liaison will assist in developing and implementing a standardized procedure for filing, retrieving, charging-out, and re-filing the records.

(f) Non-record material and personal papers are not to be interfiled with Federal records. Personal papers shall be clearly designated as nonofficial and shall at all times be filed separately from the official records of the office. In cases where matters requiring the transaction of official business are received in private personal correspondence, the portion of such correspondence that pertains to official business shall be extracted and made a part of the official files.

(g) Permanent records are to be filed separately from temporary records and must be made available in a medium and format that conforms to the NARA standards for permanent records.

(h) Temporary records will be clearly identified through labeling and indexing and will not be interfiled with permanent records or non-record material. Temporary records eligible for disposition will be removed from active files at least annually. Temporary records in inactive storage areas will be dispositioned in accordance with RCS 10-1. If disposition is destruction, the destruction will be documented on VA Form 7468, Request for Disposition of Records.

(i) Working files, such as preliminary drafts and rough notes, and other similar materials shall be maintained for purposes of adequate and proper documentation if:

1. They were circulated or made available to employees, other than the creator, for official purposes such as approval, comment, action, recommendation, follow-up, or to communicate with agency staff about agency business.

2. They contain unique information, such as substantive annotations or comments included therein, that adds understanding of the agency's formulation and execution of basic policies, decisions, actions, or responsibilities.

(j) Electronic Mail (Email) can be a Federal Record. Personal Email must be kept separate from official record Emails. Email records must be maintained in a recordkeeping system, either printed out and filed, or saved in an electronic records management application.

(k) Records or information obtained from other Government agencies will be maintained in accordance with VA and VHA records management policies.

(3) Disposition of Federal Records.

(a) Annually, RL(s) will review RCS 10-1 and disposition records that meet the retention timelines.

(b) Records destruction will be documented on VA Form 7468.

(c) The RL is required to promptly contact the Records Manager when records are improperly disposed of or damaged. The Records Manager will send a memo to the VHA Records Officer that includes record description, volume, date of incident, etc. The VHA Records Officer will submit the report to NARA.

(d) The Records Manager and Records Liaison(s) will ensure all Federal records, regardless of type, are stored in accordance with 36 CFR 1234 and VHA Directive 6300. All records boxes will have a completed VA Form 7468 affixed to the outside of the box, identifying the contents of the box.

(e) Non-records should be destroyed after their purpose has been served.

(f) Personal papers may be disposed of at any time

(g) Working files may be destroyed when the finalized document is published.

(h) Electronic Media is a general term that refers to media on which data are recorded via an electrically based process. This includes electronic storage media such as floppy disks, CDs, hard disk drives, memory sticks, and audio or videotapes that contain VA sensitive information. Electronic Media sanitization shall be documented on VA Form 0751 and VA Form 7468.

(i) Permanent records shall be protected from disposition. Permanent records must be offered to the National Archives at the earliest possible time, when they cease to be needed for the conduct of day-to-day business. If the offer is accepted, immediate action must be taken to transfer the records. NOTE: VHA records that are more than 30 years old and have not been appraised since 1990 must be offered to NARA as permanent records, or their continued retention by VHA must be justified in appropriate records appraisal documentation.

(j) Unscheduled records must be protected from disposition and retained until a disposition authority is approved from NARA. Unscheduled records should be identified clearly on the outside of the box as “unscheduled records- do not destroy”.

b. Essential Records . Essential records are critical to the continued function or reconstruction of an organization during and after an emergency. Essential records are categorized as either Emergency Operating Records (Category A Essential Records) or Legal and Financial Rights Records (Category B Essential Records). Essential records must be identified and listed on the respective service’s file plan, as well as adequately protected, current, and accessible at all times.

(1) Category A Essential Records Emergency Operating Records are required by VA medical facilities senior leadership, emergency management coordinators, and other persons as determined by the facility Director or Incident Command Center. Category A records assist with accomplishing essential functions during and immediately following a natural or technological disaster. These records can be in paper format to avoid reliance on electronic or other special equipment. Category A records are commonly located in an Emergency Management Plan maintained by the Emergency Management Coordinator, with hard copies also pre-positioned at each emergency relocation site. Examples of Emergency Operating Records include:

(a) Emergency Plans and Directives (Continuity of Operations Plan, or COOP);

(b) Orders of succession;

(c) Delegation of Authority;

(d) Staffing assignments;

(e) Employee call-back rosters;

(f) Records of a policy or procedural nature that provide staff with guidance; and

(g) Information resources necessary for conducting operations during an emergency and for resuming normal operations at its conclusion.

(2) Category B Essential Records Legal and Financial Rights Records are the type of essential records needed to protect the legal and financial rights of individual citizens and the Government. They are required to carry out VHA’s essential functions after a period of immediate emergency. Category B records are not necessary immediately following an emergency. As such, record storage does not have to be at or in the vicinity of the emergency relocation sites, and the records do not have to be solely in paper form. Examples of Legal and Financial Rights Records include:

(a) Construction Contract Records, New files, Additions, Changes (including real estate leases);

(b) Patients’ and Members’ Accounts, whether Active or Inactive during the year;

(c) Personal Funds of Patients;

(d) General Post Fund, VA Form 10-1083;

(e) Patient Data Card Listing File;

(f) Daily Gains and Losses Sheets File; and

(g) Payroll Records.

(3) Consult with the Emergency Management Preparedness Coordinator to determine vulnerabilities and risks. Risk assessment is a continuous process improvement exercise that must be tested on a regular basis, but at least annually.

NOTE: Many of the essential records noted in VA Handbook 6300.2/1 are no longer maintained in paper format and are now part of electronic information systems (EISs).

These records may be stored and backed up at multiple locations, precluding the need to print hard copies and mail the essential records to an off-site record storage facility for safeguarding.

c. Inventory/File Plan. A Records Inventory and File Plan is a descriptive listing of each record series or electronic system, together with an indication of location and other pertinent data. Its main purpose is to control the lifecycle of the agency’s records and assist with locating vital/essential records which have special recordkeeping requirements.

(1) The Record Liaison will utilize MetaKnowledge Repository (MKR) to complete their official electronic service/department inventory/file plan on an annual basis or more frequently as appropriate.

(2) The complete Master Records Inventory/File Plan must include all services, all records (whether paper or electronic), all locations (including EIS, shared drives, and

SharePoint folders), and other electronic storage devices (external hard drives, CD/DVDs). In addition, the inventory must include records maintained in off-site storage (i.e. commercial locations, Federal Record Centers (FRC), and VHA Records Center & Vault (RC&V)), as well as any on-site storage locations within the facility grounds.

(3) While conducting initial records inventory/File Plan and during annual updates, the RL conducting/reviewing the inventory must review all areas, to ensure records are not stored in inappropriate locations, such as in basements, maintenance/utility rooms, outside sheds, or under stairwells. These locations do not meet the NARA regulations for storing federal records.

(4) The Records Inventory and File Plan must be maintained by the respective records liaison and facility records manager/program office coordinator for inclusion in the Master Records Inventory and File Plan.

(5) Updates to the Records Inventory and File Plan must be conducted at least annually or in the event of an office changing physical location, dispositioning/destruction of records, or when events change the data in the File Plan.

The Master Facility Records Inventory and File Plan maintained by the facility records manager/program office coordinator must be a current and accurate listing of all facility individual Record Inventories and File Plans.

d. Safeguarding of Records.

(1) All Federal records and information, regardless of format or medium, must be safeguarded in accordance with applicable Federal laws and regulations, throughout their lifecycle. Information on Veterans, beneficiaries, employees, and others having dealings with VHA, including proprietary information, will be collected only when legally authorized and will be protected from unauthorized disclosure.

(2) The laws, regulations, and policies that apply to records and information maintained and used by the facility also apply to records and information maintained and used on behalf of the facility by contractors and those covered by a Business Associate Agreement (BAA) or Memorandum of Understanding (MOU).

(3) Federal records will only be removed in accordance with facility policy.

e. Litigation Holds and Records Freezes. Records Managers must collaborate and coordinate with the Regional Office of General Counsel in all aspects of litigation holds and freezes.

(1) Good faith efforts must be made to identify and retain all potentially relevant material. Take all reasonable steps to identify and preserve any relevant information, including the following safeguards:

(a) Retain all relevant information;

(b) Do not delete, discard, overwrite, or destroy any information that might be relevant even if it appears unimportant. If any relevant information is scheduled for destruction, the destruction must be suspended;

(c) Forward or distribute the OGC litigation hold memorandum to authorized personnel who might have relevant information; and

(d) Notify the OGC attorneys identified in the formal litigation memo if an employee with relevant information might leave VA before the information is collected.

(e) Refer to the facility SOP for additional information related to the litigation hold/records freeze process.

(2) Once a records freeze/hold is lifted, OGC will notify the agency/facility involved.

Once written notification is received that the litigation hold has been lifted, normal dispositioning in accordance with VHA/NARA approved records control schedules can be resumed. NOTE: It is still the responsibility of the facility Records Manager to check the OGC litigation hold site monthly, at a minimum, for any new holds or releases, per VHA Directive 6300.01.

f. Management of Records for Telework Personnel.

(1) Employees who meet the criteria for telework may participate in telework arrangements in accordance with applicable laws, and collective bargaining agreements. If an employee has been approved for teleworking, the federal records impacted by the teleworking arrangement must be managed in accordance with this section.

(2) Regardless of where an employee works, he/she must continue to manage their official government records (work product) in accordance with 44 USC 2901, 36 CFR 1228, VHA Directive 6300, RCS 10-1 and the NARA GRS records schedules. At times this may be difficult to accomplish but all efforts must be taken to protect government records regardless of where they are created and stored.

NOTE: Electronic records are treated the same as any other record found in a filing cabinet; the only difference is the method of storage in electronic media.

(3) If the teleworking employee maintains Federal records at their physical location, an inventory/file plan will be submitted to their assigned service’s Records Liaison.

g. Evaluating and Monitoring the Records Management Program. Regular monitoring of the facility Records Management program is a critical element in ensuring the program is effective, sustainable, and is compliant with VHA Directive 6300.01.

(1) In accordance with VHA Directive 6300.01, the facility Records Manager will create facility-specific procedures and documented monitoring processes. Documented monitoring shall include: general program monitoring, master inventory/file plan monitoring, monitoring of records storage, maintenance and disposition (to include active and inactive records and commercial storage spaces), records under a litigation hold, essential records, electronic records, permanent records, physical assessments of the facility, contracts, Business Associate Agreements and other agreements, facility policies, system of records, retention requirements specified in Privacy Threshold Assessments and Privacy Impact Assessments, records management training and awareness, and adverse incidents involving Federal records.

(2) All monitoring will be documented and retained in accordance with VHA Records Control Schedule 10-1.

(3) Quarterly, the Records Manager or Alternate Records Manager will complete the Facility Self-Assessment and submit required documentation to support the responses to the evaluation points. Documentation includes compliance monitoring processes and data; facility policies, etc.

(4) Tri-annually, or more frequently (as deemed by the Privacy Compliance Assurance Officer), the Records Manager and Alternate Records Manager will participate in the scheduled Records Management program audit and submit required documentation which supports the audit process.

5. DEFINITIONS

a. Audiovisual Records. Records in pictorial or aural form, which include: motion pictures, still pictures, sound recordings, video recordings, graphic materials such as posters and original art, audio and video recordings and combinations of media such as slide tape productions.

b. Disposition. Disposition means an interim or final placement of records or recorded information and the actions taken to maintain them in a proper place following their appraisal. This includes the actions of (1) retaining; (2) transferring to a records center for temporary storage; (3) transferring to an archival agency; (4) donation to an eligible repository; and (5) image reproduction or destruction.

c. Disposition Authority . The legal authorization obtained only from the Archivist of the United States, National Archives and Records Administration (NARA), for the disposal of records and recorded information.

d. Electronic Records. A category of computer processed records in which the information is represented by electronic impulses on a magnetic medium; such as magnetic tape, disk, and optical disk, and which requires the use of specialized equipment to convert the information to human-readable form.

e. Essential Records. Records critical for maintaining the continuity of facility activities during and following a national or regional emergency (36 CFR Part 1223).

f. File Plan. A file plan allows for consistent filing practices which is critical for an effective and efficient record program. A file plan contains identifying numbers, titles, descriptions, disposition authority, and retention periods of all records held in an office or program. The file plan also contains the location of all records, including paper, electronic, and special media and how the records are to be arranged.

g. General Records Schedule. The NARA General Records Schedule (GRS) contains the retention and disposition requirements for records and information that are common to two or more Federal agencies. The disposition requirements of the GRS, including record retention periods, are mandatory VA-wide unless an exception is obtained from NARA. The GRS does not cover all VA/VHA records. Citations from the GRS will be used in VHA records control schedules as the authority for disposition of VHA records whenever applicable.

h. Information System. Discrete set of information resources organized for the collection, processing, maintenance, use, sharing, dissemination, or disposition of information.

i. Life Cycle of Records . The management concept that records pass through three stages: creation, maintenance and use, and disposition. Safeguarding measures will be applied to all records through all stages of their lifecycle.

(1) Creation. The records life cycle is initiated by the development, collection, and receipt of records in the form of data or documents; in any medium (i.e. paper, film, disk, or electronic file) and format (i.e. electronic, audiovisual, microfilm, architectural, engineering, or printed) in the course of carrying out administrative, program, and clinical responsibilities and needs of the facility. Records disposition must be considered as part of the architecture of any new record development or updates/corrections or modifications to existing records.

(2) Maintenance and Use. The records life cycle continues through the preservation and use of the record which includes filing, retrieving, use, duplication, printing, dissemination, release, and exchange of the records. The facility will maintain and preserve records necessary to protect the legal and financial rights of the government and of persons directly affected by its activities. Reasonable efforts will be made to preserve records in an appropriate format or media for reproduction under the Freedom of Information Act (FOIA). Duplicate records will be prepared only in amounts required for the efficient operations of the medical center or as required by Federal regulations.

(3) Disposition. The final stage in the life cycle is disposition, which means records are no longer needed for current facility business. Disposition includes storage, transfer, preservation, and destruction of the records. Disposition of records will be made in a timely manner (within the fiscal year/calendar year of cutoff) and in accordance with the VHA Records Control Schedule (RCS) 10-1.

j. Litigation Holds. Also known as Legal Holds, a litigation hold is a formal instruction from the Office of General Counsel to preserve all records, including any that are scheduled for routine destruction, which may be needed as evidence in litigation, investigation, audit, merger, or other special circumstance. Litigation Hold records must be clearly marked and appropriately safeguarded to prevent premature destruction.

k. Non-record Material . Informational materials that do not meet the statutory definition of records (44 U.S.C 3301) or that have been excluded from coverage by definition. Excluded materials are extra copies of documents that are kept only for reference, stocks of publications and processed documents, and library or museum materials included solely for reference or exhibit (36 CFR 1220.14).

l. Permanent Records and Information. Permanent (archival) records are defined as records that have been appraised by VA and NARA and approved by NARA to have sufficient historical value or other value to warrant permanent preservation at the National Archives. Those records that have enduring historical or other value and will never be removed from Federal custody. In United States Government usage, records and information appraised by VA and approved by NARA as having enduring value because they document the organization and functions of the agency that created or received them and/or because they contain significant information on persons, things, problems, and conditions with which VA dealt, and for which there is no plan for destruction.

m. Records. All books, papers, maps, photographs, machine-readable materials, or other documentary materials, regardless of physical form or characteristics, made or received by an agency of the United States Government under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the Government or because of the informational value of data in them (44 U.S.C. Chapter 33, Sec. 3301).

n. Records Appraisal. The process of determining the value and, thus, the final disposition of records and information based upon their administrative, financial, and other uses, their evidential, legal, and informational or research value, their arrangement and relationship to other records, and their historic value to VA, other agencies of the Federal Government, or to the general public.

o. Records Control Schedule (RCS) 10- 1. RCS 10-1 contains the VHA-specific schedules covering records and record series that are unique to the VHA; it supplements the GRS. RCS 10-1 applies to records maintained in the Veterans Health Administration (VHA) field facilities and Central Office VHA program offices.

p. Records Freeze. Temporary records held locally for litigation, investigation, or audit purposes, specially marked or flagged as “frozen” by the Records Manager.

Frozen records can be destroyed only after completion of the litigation, audit or investigation.

q. Records Inventory. A survey of agency records conducted primarily to develop records schedules and to identify records needs. The record inventory will include the date prepared, department or program creating the inventory, person conducting the inventory, record location, record series, description of the record, inclusive dates of information in the series, disposition, and type of medium (paper, electronic, audiovisual, etc.). Both electronic and non-electronic records should be included in the record inventory.

r. Records Liaison. Service line representative who works in conjunction with the Records Manager to ensure proper management of records created and maintained by the service line.

s. Records Management. The managerial activities involved with respect to records creation, maintenance and use, and disposition of records to achieve adequate and proper documentation of the policies and transactions of the Federal Government and effective and economical management of VA operations.

t. Records Manager (Facility, VISN, VACO Service/Department). Person designated responsibility for managing and coordinating a records management program for their respective organization.

u. Records Officer (VHA). The person assigned responsibility by the agency head for overseeing an agency-wide records management program.

v. Records Series. File units or documents arranged according to a filing system or kept together because they relate to a particular subject or function, result from the same activity, document a specific kind of transaction, take a particular physical form, or have some other relationship arising out of their creation, receipt, or use, such as restrictions on access and use. Each series of records should be documented on a file plan which promotes ease of access to the information as appropriate.

w. Shadow Records. Shadow records are defined as duplicate health records that are kept for the convenience of a department or health care provider. The elimination of shadow records should be considered based on utilization of the electronic health record by the facility. Shadow records must not contain original documentation of the patient’s care. Original documentation must be kept in the official health record.

x. SharePoint . SharePoint is a tool that allows people to collaborate on current active documents that may be Federal records. SharePoint does not meet DoD Standard 5015-2 and should not be considered an electronic recordkeeping system.

Official records must be maintained on the network drive and in accordance with the department’s file plan.

y. Temporary Records. Temporary records are records which will be destroyed or otherwise removed from Federal Government control after a fixed period of time or after occurrence of a specified event, and records approved by NARA for disposal, either immediately or after a specified retention period.

z. Unscheduled Records. Records that have not been evaluated to determine their record retention value, i.e., retention and disposition standards. Such records are to be retained until they receive disposition authorities from NARA. Records whose final disposition has not been approved by NARA.

aa. Working Files. Documents such as rough notes, calculations, or drafts assembled or created and used to prepare or analyze other documents. Also called working papers.

6. REFERENCES

a. VA Directive 0320, VA Comprehensive Emergency Management Program .

b. VA Directive 6300, Records and Information Management .

c. VA Directive 6301, Electronic Mail Records .

d. VA Directive 6371, Destruction of Temporary Paper Records .

e. VA Handbook 0320, Comprehensive Emergency Management Program

f. VA Handbook 6300.2, 6300.2/1, Management of the Vital Records Program .

g. VA Handbook 6300.5, Procedures for Establishing and Managing Privacy Act Systems of Records.

h. VA Handbook 6301, Procedures for Handling Electronic Mail Records .

i. VA Handbook 6500, Risk Management Framework for VA Information Systems – Tier 3: VA Information Security Program.

j. VA Handbook 6500.6, Contract Security .

k. VA Memorandum 796-13-02, Guidance for Recycling of X-ray film and Precious Metal. http://vaww.va.gov/oal/docs/sdc/memo796-13-02.pdf

l. VHA Directive 0320, Comprehensive Emergency Management Program, dated April 12, 2013.

m. VHA Directive 0320.01, Veterans Health Administration Comprehensive Emergency Management Program (CEMP) Procedures, dated April 6, 2017.

n. VHA Directive 6300.01 Records Management Compliance Monitoring, dated August 17, 2017.

o. VHA Records Control Schedule 10-1 .

p. Department of Veterans Affairs – Health Information Management Web site.

q. Department of Veterans Affairs – Training Management System .

r. OPM Official Guide to Personnel Recordkeeping .

s. National Archives and Records Administration – Federal Records Centers .

t. National Archives and Records Administration – Records Storage Standards Toolkit.

u. National Archives and Records Administration - Request for Records Disposition Authority.

v. National Archives and Records Administration. Records Management Training Program YouTube Playlist.

w. National Archives and Records Administration – Universal Electronic Records Management (ERM) Requirements.

x. Veteran’s Health Administration – Employee Education System .

7. RESCISSION

MCM Information Security 00-022, Records Management Policy, dated February 2017, is rescinded.

8. REVIEW

At minimum at recertification and including when there are changes to the governing document (for example, national policy or a health care accreditation body mandate).

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of April 2025.

This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

Chris Frani Acting Medical Center Director Date Approved: April 3, 2020

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

DISTRIBUTION: MCPs are available at: Syracuse Medical Center Document Control SharePoint (DCS).

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT SYRACUSE

Medical Center Professional Memorandum October 2018 Chief of Staff 11-13

MEDICAL RECORDS STANDARDS

I. PURPOSE:

To establish standards for complete, timely, accurate and clinically pertinent Health Information at the Syracuse VA Medical Center.

II. POLICY:

A. VHA (Veterans Health Administration), 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, as well as fiscal operations and legal requirements.

B. The most current standards of the Joint Commission (JC) must be followed, unless otherwise specifically stated.

C. The record must be standardized with regard to content, creation, maintenance, management, processing and expected quality measures.

Electronic capture and storage of patient health information will be implemented to enhance access to patient data by health care practitioners and other authorized users. Electronically stored and/or printed patient information is subject to the same medical and legal requirements as handwritten information in the health record.

III. RESPONSIBILITY:

A. The Chief of Staff, or designee (equivalent), has ultimate oversight responsibility for health record timeliness, accuracy, clinical management of the health record and completion.

B. The Attending Physician shall be responsible for the accuracy of the medical record for each patient under his or her care.

Medical Center Professional Memorandum October 2018 Chief of Staff 11-13 Page 2

C. Health care providers shall be responsible for completing their respective notes for patients under their care. The author of the entry is responsible for completing, authenticating and correcting any health record deficiencies within 5 days of the visit/discharge.

D. All Syracuse VAMC employees who are involved with direct patient care are responsible for documenting patient care activities in CPRS (Computerized Patient Record System).

E. Administrative Management of the health record is the responsibility of Health Information Management (HIM).

IV. PROCEDURES:

A. General Guidelines:

1. The medical record is comprised of progress notes, lab, radiology, consults, treatment plans and other necessary documents to assist with quality patient care. In all cases the medical record must clearly demonstrate the active involvement of the attending physician.

2. The primary source of documentation for all patient care activities shall be CPRS. Electronic input of data, in conjunction with the Syracuse VAMC initiative to achieve a complete electronic medical record, should be pursued in all cases where a manual system of entry still exists. All entries will be in English.

3. Medical and administrative processing of inpatient records and completion of deficiencies by the responsible parties will be accomplished within 5 calendar days of discharge.

4. All parts of the medical record as described in this memorandum must be completed before a record will be considered complete for filing purposes. Problem cases will be referred to the Lead Specialty Physicians, Careline Leaders, Chief of Staff or designee for final disposition, as appropriate.

Chief of Staff 11-13 Page 3

5. A complete medical record is defined as any inpatient record with complete Operation Report and Discharge Summary for the inpatient stay. A record is considered delinquent when the discharge summary and/or Operation Report is not complete (undictated, unsigned, or uncosigned) within 5 days of discharge.

6. All entries must be accurate, relevant, timely and complete and will be recorded and authenticated immediately after the care event or observation has taken place to ensure that the proper documentation is available.

7. The use of disclaimers when proofreading transcribed medical records or notes entered utilizing Speech Recognition Technology (SRT) compromises patient safety and is strictly prohibited.

8. All entries in the record will be authenticated by time, date, signature and professional designation of the practitioner credentials in the signature block. The signature in the electronic record will be electronically time stamped upon completion.

Prior to authentication with an electronic signature, CPRS documentation can be edited on line. After a document is signed, all requests for corrections need to be handled by the Privacy Act Officer or designee for determination of appropriateness of request.

9. Only authorized individuals may document in the health record.

All entries should be in CPRS except those instances where technology is not available for electronic entry. Author(s) and any required cosigner(s) are to be identified. Rules must be in concert with facility Bylaws, policy as well as VISN policy.

B. The following staff may make note entries into patient medical records as follows:

1. Clinical Staff: All clinical staff who, by virtue of a position description, functional statement, statement of work, affiliation agreement, sharing agreement, clinical privileges, or scope of practice, when providing patient care are authorized to document care and authenticate (sign) their documentation in the medical record. The term "clinical staff' includes members of the medical

Chief of Staff 11-13 Page 4 staff, allied healthcare staff, house staff, and healthcare professionals practicing under an approved scope of practice.

2. Administrative Staff: Administrative staff, who are authorized on a case-by-case basis by the Health Information Committee may make note entries in the medical record that are administrative in nature but are related to clinical care and support clinical functions.

These notes are authored and electronically signed by the administrative employee (i.e. telephone discussions, appointment/consult cancellations/no shows, and lab order entries).

3. Scribes: Certain administrative staff may, upon approval by the Health Information Committee, use specified note titles and function as a scribe for groups of clinicians writing clinical notes;

e.g., group case evaluations, interdisciplinary care planning and patient care conferences.