D.40- ADMINISTRATIVE CLOSURE OF INCOMPLETE NOTES SOP.pdf

ADMINISTRATIVE CLOSURE OF INCOMPLETE NOTES

SOP 00A2-004

Syracuse VA Medical Center Syracuse, NY 13210

Signatory Authority:

Business Operations Manager

Responsible Owner:

Health Information Management (HIMS) Chief

Service Line(s):

All Service Lines

Effective Date:

February 2022

Recertification Date:

February 2027

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on administrative closure of Notes by the Health Information Management Section (HIMS) Manager. This SOP must be followed by all VA Staff and Contractors.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 1907, VHA Health Information Management and Health Records, dated April 5, 2021.

2. PROCEDURES

a. Administrative Closure. The following steps should be followed:

(1) In Computerized Patient Record System (CPRS), select the patient and then click on the Notes tab.

(2) Bring up the Unsigned/Un-cosigned Note:

(a) Select View from the Toolbar

(b) Choose Custom View

(c) Under Status select Unsigned or Un-cosigned Documents

(d) Enter Author’s Name

(e) Hit OK to bring up incomplete note(s) by the identified Author

(3) Open the note approved for Administrative Closure

(a) Go to Action on the Toolbar or right click in the blank space and select ‘Sign Note Now’. (For un-cosigned notes you will need to change the cosigner to your name before signing.)

Attachment D.40 RFP 36C24224R0049

February 2022 SOP 00A2-004

(b) Sign Note by entering your electronic signature.

(c) Add the following statement verbatim as an addendum to the note:

1. This record is being closed administratively due to the fact that the provider is permanently unavailable. This statement does not legally imply that the signer is validating the contents of the document but is only administratively completing the medical record. Approval for the administrative closure was given by the Executive Committee of the Medical Staff on (insert date).

3. ASSIGNMENT OF RESPONSIBILITIES

a. HIMS Chief. HIMS Chief is responsible for:

(1) Reviewing all records being considered for administrative closure.

(2) Getting approval from the Service Chief, Health Information Committee (HIC) and Medical Staff Executive Committee (MSEC) prior to administrative closure of incomplete documents.

(3) Following the steps identified under Procedures for Administrative Closure of Incomplete Notes.

b. Service Chiefs. The Service Chiefs are responsible for:

(1) Ensuring notes are completed timely so they are available in CPRS for continuity of care, 1st, and 3rd party release of information (ROI) requests, Freedom of Information Act (FOIA), and coding.

(2) Enforcing completion of all outstanding notes prior to an employee separating from the Syracuse VAMC. All staff who enter notes in CPRS are required to sign out with HIMS upon their departure unless there are extenuating circumstances.

Administrative closure should be a last resort.

(3) A Closure of Medical Record form (Attachment A) will be completed for those medical records which have been determined impossible to complete. The reason for non-completion will be stated and refer the record to the HIMS Chief for review by the

HIC.

(4) For un-cosigned notes, the Service Chief can direct their administrative personnel make a request through HIMS to change the original attending co-signer of any note in their department to an administrative Service Chief signature if that Service Chief determines that signing of that note is required to safely expedite a patient’s care.

(5) The completion of this request form does not legally imply that the Service Chief/Line Manager is validating the information for the episode of care but is only requesting it be administratively completed.

February 2022 SOP 00A2-004

4. DEFINITIONS

None.

5. REFERENCES

VHA Directive 1907.01, VHA Health Information Management and Health Records, dated April 5, 2021.

6. REVIEW

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

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of February 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Michael Van Zummeren Business Operations Manager Date Approved: February 16, 2022

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

DISTRIBUTION: SOPs are available at: Syracuse Medical Center Document Control SharePoint (DCS). https://dvagov.sharepoint.com/sites/VHASYR/svdc.

Attachment A

Attachment A: Closure of Medical Record Form https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://dvagov.sharepoint.com/sites/VHASYR/svdc/ https://dvagov.sharepoint.com/sites/VHASYR/svdc/ https://dvagov.sharepoint.com/sites/VHASYR/svdc/ https://dvagov.sharepoint.com/sites/VHASYR/cprs/Provider%20Clinical%20Documents/Misc%20Forms%20and%20Documents/FINAL%20CLOSURE%20OF%20MEDICAL%20RECORD.pdf?CT=1645016985237&OR=Outlook-Body&CID=81AEC2A4-3AED-4C97-A17E-A95624BCBDB5