S02 - Attachment 12 - Numbered Memorandum 136-27-13 Medical Records.doc

Attachment 12

PAGE

Attachment 12

VA Medical Center

Numbered Memorandum 136-27-13 Spokane WA

April 26, 2013

MEDICAL RECORDS

1. PURPOSE: To establish policy, responsibility, and procedures for the maintenance, analysis, and completion of all medical records of the Veterans Administration Medical Center (VAMC). Medical record policies and procedures are extended to encompass both electronic and hard copy records.

2. POLICY: It is the policy of this medical center to maintain medical records that will completely satisfy the multiple professional, managerial, and accreditation requirements. Electronic storage of patient medical information will be implemented to the extent possible to enhance access to patient data by health care providers and support personnel who have a need to know in association with their jobs. The electronically stored and/or printed patient information is subject to the same medical and legal requirements as that which is handwritten in the official medical record.

a. The standards for the medical records will be those given in the Joint Commission manuals unless amended by VHA Handbook 1907.01. Where policies and/or procedures established in Veterans Health Administration (VHA) directives conflict with Joint Commission interpretations, Veterans Affairs (VA) policies and procedures will be followed.

b. Medical records should be complete, concise, legible, relevant, and accurate. They should reflect dialogue between members of the health care team/patient/family by documenting all aspects of the patients care. Records should contain adequate information to support the diagnoses established; the procedures undertaken; and the treatment provided for the continuity of ongoing patient care with the VA system and/or the community.

c. Medical records will be completed in a timely fashion according to Joint Commission standards and medical staff rules and regulations. The Electronic Health Record (EHR) is considered to be delinquent if not completed within 30 days from patient’s discharge (complete is defined as all documentation/authentication is provided as required for reporting purposes.)

d. Medical records are confidential and should only be available to those individuals having a legitimate reason and/or valid authorization. These records cannot be removed from this medical center except by court order or by sending the record to archives. Procedures related to the transfer and loan of medical, administrative, and perpetual records will be controlled by the Chief, Health Information Management (HIM).

e. All authorized users of the Veterans Information System Technology Architecture (VISTA) computer system are responsible for complying with the procedures of confidentiality, security, and release of information and safeguarding electronic signature codes.

f. Service chiefs and supervisors are responsible for ensuring their staff understand, comply with and are trained in the security and release of information procedures involving the EHR and electronic signatures.

g. The Chief, HIM, or designee, is responsible for release of information. Additionally, all amendments or corrections to electronic patient records shall be requested and coordinated through the Privacy Officer. HIM designees are responsible for archiving and transferring the paper medical record.

h. The Facility Chief, Information Officer, and designees are responsible to assist with the support and maintenance of software and hardware to include the effective storage of electronic patient records.

i. A terminal digit unit numbering system will be used to identify each medical record. The social security number of the person receiving care will be the unit number designed as the medical record number and will remain the same for all episodes of care.

j. The privacy and security of patient information stored in any media shall be protected in accordance with, but not limited to, the Privacy Act of 1974, Freedom of Information Act, Federal Information Security Management Act, Office of Management and Budget (OMB) Circulars A-123 and A130, Health Insurance Portability and Accountability Act of 1996 (HIPAA), Title 45 Code of Federal Regulations (CFR) Parts 160 and 164, and Joint Commission standards.

(1) Patient records are confidential regardless of medium. The privacy of patient information must be preserved and the information will not be accessible to, or discussed with, unauthorized persons.

(2) All staff with access to patient information in the performance of their duties are informed of the need to maintain confidentiality of patient information.

(3) All VAMC personnel with access to patient records in any medium are responsible for proper handling of the patient records. All personnel are accountable for safeguarding patient confidentiality and privacy, and failure to do so may result in disciplinary or other adverse action up to, and including, termination.

(4) Access to health care information is controlled to ensure integrity, to minimize the risk of compromising confidentiality, and to increase reliability.

(5) Access to health records and health record file areas is limited to authorized personnel. Only authorized personnel are allowed to print extractions from the electronic record or to make copies from the paper chart.

(6) Paper health records temporarily stored must be locked when responsible personnel are not present to ensure the security of the area and to ensure records are not accessible to unauthorized individuals.

(7) Precautions must be taken by staff to ensure that patient records on computer screens cannot be seen by individuals who do not have a legitimate need-to-know.

(8) All patient-identifiable waste paper, or discarded materials, from any department must be shredded or disposed of in accordance with approved disposal policies and procedures. Locked containers or shredders must be provided in employee work areas for disposal of sensitive patient information.

(9) Communicating confidential patient information across local VISTA e-mail is considered appropriate to alert a recipient that there is information in Computerized Patient Record System (CPRS) from a particular day, or visit, and that the recipient should review. The subject line of e-mail must never include a patient's full name or full Social Security Number (SSN), or any patient identifying information.

k. Employee Health Records are under the management of Human Resources and are maintained in a locked file cabinet located in the file room. Only Human Resources under the umbrella of Employee Health, the Employee Health Provider and Administrative Officer of the Day (AOD) staff have access to these records. HIM staff do not have access to Employee Health Records.

l. The records of employees who receive care as a Veteran are under the auspices of HIM and are maintained in the EHR with other Veteran records.

m. Information received via facsimile (fax) is acceptable and may be scanned into the patient’s EHR. The fax machine transmittals must be limited to immediate need to render patient care. All established fax protocols must be strictly observed.

n. A confidentiality statement must be attached to the cover page when transmitting individually-identifiable health information. For example, when transmitting outside VA: "This transmission is intended only for the use of the person or office to whom it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that receipt of this fax does not waive any applicable privilege or exemption from disclosure and that any dissemination, distribution, or copying of this communication is prohibited."

3. PROCEDURES:

a. A separate, unique health record is created and maintained for every individual assessed or treated by VHA, as well as those receiving community or ancillary care at VHA expense. It is not required to print and file paper documents from electronic media for active records.

b. Only documents which cannot be found with CPRS, remote data views, or VISTA, will be scanned. Scanned documents will be made available to all clinical and support staff who currently have access to CPRS.

c. Documents will be scanned, indexed, and stored according to date of service for retrieval purposes. The Medical Records Review Committee (MRRC) will approve the types of documents to be scanned. Documents which have been approved for scanning include Informed Consents, Advance Directives/Physicians Orders for Life Sustaining Treatment (POLST)’s, Consult Reports, Electromyography (EMG) Reports, Non-VA Coordinated Care (NVCC), non-imaging vascular diagnostic Ankle/Brachial Blood Pressure Index (ABI) Graphs, Emergency Department records containing hand-written orders, and outside non-VA records that are requested to be scanned by providers.

d. Non-VA records that are to be scanned include: Discharge Summaries, electrocardiogram (EKG) Reports, Diagnostic Testing Reports, History and Physicals, Operative Reports, Pathology Reports, and Consult Reports.

e. Any other non-VA documents practitioners wish to be retained will need to be indicated by the practitioner. These should be limited to pertinent, present, and/or continued care. A summary progress note written by an appropriate clinician after a review of the external source documents may be used in lieu of scanning any external source documents.

f. Any documents or information scanned into a patient’s EHR, including external source documents, are deemed to be part of the patient’s VHA EHR. These records are subject to all applicable federal regulations concerning maintenance and disclosure including the Privacy Act of 1974 (5 U.S.C. 552a) and VA confidentiality statutes. Once a document is scanned, absent federal law or regulation to the contrary, it becomes a VA record subject to protection and release under federal law.

g. A request to amend an external source document must be referred back to the original source.

h. Ownership. The EHR and the health information within the EHR are property of VA, as specified in statute and regulations such as: the Privacy Act of 1974 and HIPAA.

i. Legibility. Legibility refers to the quality of penmanship used when recording data, including a clear, written signature, as well as content and appearance of dictated, copied, and/or scanned information. Patient safety and the general usefulness of the paper record depend on the legibility and the readability of the entries. Paper entries must be made in black ink to assure permanent recording. NOTE: Handwritten entries are being phased out and need to be limited to documents technology cannot yet support.

j. Retention Disposition and Transfer

(1) Retention policy applies equally to both paper and electronic records. VHA health record retention policy is 75 years. Retention policies and guidelines are detailed in VHA Records Control Schedule (RCS) 10-1. Disposal procedures are set forth in 44 U.S.C. Chapter 33.

(2) Veteran records will be stored in CPRS. All Veteran paper records are located at the Federal Records Center and will be maintained there for 3 years following last patient activity. Paper records may be retired to the VA Records Center and Vault (VA RC&V) after 75 years following the last patient activity. Employee records are transferred to the receiving facility if the employee transfers to another VA facility. If the employee leaves federal service or transfers to a non-VA facility, the paper records are forwarded to VA RC&V where they are maintained for a minimum of 30 years.

(3) Health records may be copied, loaned, or transferred to other VA facilities that have a need for the information in the performance of their duties (treatment, examination, research, adjudication, and other related purposes).

k. Symbols and Abbreviations. A list of unapproved symbols and abbreviations is available to all those who make entries in the health record and to others who use health records in the course of their official duties by using the tools option in CPRS. Symbols and abbreviations are not to be used when documenting final diagnoses and procedures on patients released from inpatient and ambulatory and/or outpatient services.

l. Forms and Template Management

(1) A local process for initiating, developing and approving new electronic templates and overprinted paper health record documents is established under the auspices of the medical record review function.

(2) All internally generated forms and shared templates that become part of the health record must receive prior approval from the Medical Records Review Committee. Requests for new forms and templates are to be limited to those that can be developed in an electronic format. Overprints must accompany requests for electronic forms for contingency purposes.

(3) As part of the medical record review function, proposed templates must be reviewed for legal, policy and regulatory compliance, and ease of use. Requests must be approved prior to implementation.

(4) All components must reflect patient identifier information (full name, date of birth, and only the last 4 digits of the Veteran’s SSN), date of documentation, date of service, and facility name. The patient name, SSN (last 4 only), and date of birth are used to identify the patient and must be on each side of every page where there is documentation.

(5) Locally developed forms (also referred to as OP [Overprint] Forms) will be reviewed by the Office of Primary Responsibility (OPR) and/or the Service Line Chief every two years to ensure relevancy. Forms that are no longer relevant should be rescinded; keeping in mind that all templates created for “public” use in CPRS must have a “paper” back-up in the event of computer systems failure. Odd-numbered forms will be reviewed on odd-numbered years; even-numbered forms will be reviewed on even-numbered years. This review must be completed by March 31st of the appropriate year. Forms not reviewed and re-certified within these time frames will be rescinded.

m. Authentication. Authentication demonstrates that the entry has not been altered. Authentication includes the time, date, and signature or initials and the professional designation of the practitioner (credentials).

(1) Each clinical record user must keep current their electronic signature block. This ensures non-repudiation and that appropriate billing occurs. Authentication functionality must include the identity and credential and/or professional discipline of author, the date signed, and the time signed, if required. If the title block is used, it needs to accurately reflect the functional position of the user as defined by the service. As employees enter, leave, or transfer to a different position, the person class file and the title block must be edited to appropriately reflect job status.

(2) All entries must be recorded and authenticated immediately after the care event or observation has taken place to ensure that the proper documentation is available to ensure quality patient care.

(a) Only those individuals authorized by facility policy are allowed to make entries into the health record. Electronic signatures shall:

(b) Electronic signatures shall be treated as a written signature with all associated ethical and legal implications.

(c) Electronic signatures shall be coded and encrypted in VISTA so that no one, including IRM section staff, has access.

(d) Electronic signatures shall appear on electronic documents to authenticate and/or countersign entries. These documents may include, but are not limited to, operative and procedure reports, discharge summaries, progress notes, patient related orders, etc.

(e) The practitioner who treats a patient is responsible for documenting and authenticating the care provided. Where multiple practitioners treat during the same encounter, additional signers are strongly encouraged (for example, multidisciplinary notes in rehabilitation and psychiatry). Addenda may also be used to facilitate the documentation of multidisciplinary care.

(f) All clinical staff authorized to document in a health record must record in CPRS, except for those instances where technology is not available for electronic entry.

(g) The respective clinical staff, as defined by their scope of practice, must document every episode of clinical care.

(h) Health record entries must be completed, processed promptly, signed and/or co-signed as necessary, and transmitted, filed, and/or uploaded to ensure information is available for patient care. Health care practitioners are responsible for completing their respective notes within prescribed timelines for patients under their care.

n. Sensitive Records: Some specific record types are deemed sensitive and may be maintained under direct supervision of the health information professional, or be flagged as “sensitive” in VISTA, or other facility computerized record repositories. These include, but are not limited to:

(1) VA Veteran employee patient records. All documented entries are made in accordance with the Spokane VAMC Business Rules. Document entries that are not protected from employee access include laboratory results, EKG results, all orders including medication orders, immunization reports, and radiology reports;

(2) Regularly scheduled Veteran volunteers;

(3) Individuals engaged in the presentation of claims before VA, including representatives of Veterans’ organizations, or cooperating public or private agencies, or Administrative Tort Claims; and

(4) Records involved in Administrative Tort Claim activities.

o. Complete and Incomplete Records:

(1) Patient records must be timely, relevant, necessary, complete, and authenticated. Completeness implies that all required data is present and authenticated; all final diagnoses are recorded without use of abbreviations; and transcription of any dictated information is completed and inserted and/or uploaded into the record.

(2) Responsibility:

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

(b) The author of the entry is responsible for completing, authenticating, and correcting any health record deficiencies within the time frame defined by the facility policy or medical staff bylaws.

(c) Practitioners who write or co-sign electronic progress notes are responsible for ensuring that they are completed in accordance with VAMC policy in a timely manner (48 hours) and that unneeded printouts are disposed of according to VAMC policy.

(3) Authenticating Documents:

(a) No medical staff member is to be required to authenticate entries that are not the staff member's own in order that a record on an unfamiliar patient may be filed.

(b) A staff member may, however, summarize a course of treatment based on existing patient record documentation, or review a summary for consistency with existing patient record documentation, if the original staff member responsible for the patient's care is no longer available to do so. In such cases, a notation must be made in the record to the effect that the summarization (review) is being done from existing documentation in the absence of the medical staff member responsible for the patient's care and without personal knowledge of the patient.

The Chief of the service may sign for absent service member.

(c) The completed summarization must be authenticated and dated by the medical staff member preparing the summary and/or the supervising physician.

(4) Declaring a Record “Complete for Filing”:

(a) An inpatient record is declared “Complete” for the purpose of filing when all required documentation is present. If unusual circumstances prevent proper completion, the record must be referred to the appropriate medical staff committee for review and/or completion.

(b) When the appropriate medical staff committee declares an incomplete record to be filed as complete, the record must be so noted with portion(s) known to be incomplete, and reason(s) normal completion could not be accomplished, and must be documented in an administrative progress note, and signed by the health information management professional, or designee.

(c) A sample statement such as “Approved for filing incomplete on (date) by Medical Staff Committee due to (reason)” may be used to note the record as incomplete. This statement does not legally imply that the signer is validating the contents of the document, but is only administratively completing the health record. This statement must not be used on a routine basis to close records due to the failure of an available physician to sign the documents.

(5) Preparing Records for Litigation. Records for litigation with unsigned, or with incomplete entries, must be presented for court in exactly the same manner the records existed at the time the facility received the court order for the records. The same applies for records requested by Regional Counsel. If the facility needs to complete and/or sign the records in order to comply with VHA and facility policy, it needs to be done after providing the unsigned copy to the requestor.

p. Adverse Event and Close Call Reporting

(1) Adverse events and close call reporting is the reporting, review, or analysis of events involving patients and systems that cause harm or have the potential for causing harm to patients.

(2) To report Patient Safety Events complete an electronic Patient Safety form located on the desktop. Event forms include patient falls, missing patients, medication events, and safety events. Once completed the form will be submitted to the Patient Safety Manager for assignment of a Severity Assessment Code and tracking of events.

(3) All Patient Safety Events are protected and will not be filed in the patient record.

(4) Copies, notes, or documentation of any investigation concerning patients are confidential, privileged, and are not to be scanned or become part of the patient’s health record.

q. Copy and Paste (Cloned Notes)

(1) The electronic function of copy and paste is a powerful tool; however, this functionality must be used with caution and according to strict and enforceable policy. Clinical, financial, and legal problems may result when text is copied in a manner that implies the author or someone else obtained historical information, performed an exam, and/or documented a plan of care when the author or someone else did not personally do it.

(2) Copying information from other documents in VISTA is unnecessary duplication of information that does not assist those reading the record. Repeating information does not provide any advantage, but instead makes reading the charts more difficult and time consuming; copied portions of notes and other data is overwhelming to the reader and dwarfs the remaining information within the note.

(a) Copy and paste tenets

1 Never copy the signature block into another note.

2 Never copy data or information that identifies a healthcare provider as involved in care that the healthcare provider is not involved in.

3 Do not copy entire laboratory findings, radiology reports and other information in the record verbatim into a note. Data copied into the record needs to be specific and pertinent to the care provided.

4 Do not re-enter previously recorded data, unless specifically required for the assessment of a specific patient problem

5 Use the functionality of importing data objects into progress notes and other documents judiciously. Any imported object, dialog, etc., if used, must be reviewed and corrected at the source as well as in the document if there is any inaccuracy. Imported information must be pertinent to the patient assessment.

(b) Accountability

1 The authors are liable for the content of copied items within the notes they authenticate. As part of the health record review function, use of copy and paste functionality must be monitored, and where violations occur, findings must be reported to the appropriate Medical Staff Committee for disciplinary or other adverse action. NOTE: Criminal charges may be filed when in violation of federal law.

2 Failure to comply with these standards may be deemed a violation of the:

a Privacy Act requirement (5 U.S.C. Section 552a(e)(5)); or b Standards of Ethical Conduct for Employees of the Executive Branch (5 CFR Part 2635).

3 Disciplinary action may be taken if violations of these standards are validated per VA Directive 5021. Violations are:

a Charge 05 - Careless or negligent workmanship resulting in waste or delay.

b Charge 11 - Failure to safeguard confidential information.

c Charge 12 - Deliberate failure or unreasonable delay in carrying out instructions.

d Charge 25 - Falsifying official agency records.

(3) Currently, there are three types of signatures in the electronic health record:

(a) A "signer" is the author of the document. Once a document is signed, it cannot be edited or removed from the record; however, additional documentation can be added to the original document by addenda.

(b) A "co-signer" is the attending, staff, or supervising clinician. A co-signer may also be a service chief or designee as defined by the organization's bylaws and/or policies. A co-signer may review and add a signed document, and if unsigned may authenticate a document.

(c) “Identified signer" and "additional signer" are synonymous and are a communication tool used to alert a clinician about information pertaining to the patient. This functionality is designed to allow clinicians to call attention to specific documents and for the recipient to acknowledge receipt of the information. Being identified as an additional signer does not constitute a co-signature. This nomenclature in no way implies responsibility for the content of or concurrence with the note. NOTE: “Identified signer” is nomenclature used by CPRS, VISTA, and Text Integration Utilities (TIU); “additional signer” is nomenclature used by Graphical User Interface (GUI).

(4) Addendum: An addendum to a patient note or summary is made when a clinician deems it important to clarify information recorded in the original document or to add to the original document. The addendum option can be utilized by practitioners to continue ongoing treatment discussions, or by supervising practitioners to validate the plan of care.

(a) Addenda are linked to originally created document;

(b) Addenda must be authenticated in approved manner; and

(c) Addenda (or any note) must not be backdated.

(d) Addenda may be entered by someone other than the author. The original author must be alerted only when appropriate TIU functionality is activated. There are some note titles, such as discharge plans, education, and initial assessments, to which additional addenda are routinely added. NOTE: For these note titles, the parameter would typically be turned off.

(e) A new note by the practitioner must be initiated for each new patient contact rather than using an addendum.

(5) Amendment

(a) Amendment is the alteration of health information by modification, correction, addition, or deletion. A request to amend any data contained in VHA records must be submitted in writing to the Privacy Officer, by the Veteran stating explicitly what information is in contention and why, i.e., inaccurate or erroneous, irrelevant, untimely, or incomplete, date, author and title of note.

(b) When a request to amend a record is approved, the disputed information must be corrected or deleted using the TIU amend action. The TIU amend action automatically keeps the original, un-amended document with status retracted. Requests for amendments must be tracked and information recorded appropriately for disclosure purposes.

(c) VHA may deny the request to amend the health record if the health information that is the subject of the request:

1 Is not part of the individual's health record;

2 Is accurate and complete.

(6) Erroneous Notes

(a) Original author adds addendum stating note was made in error.

(b) Original author sends a “Bad Note” request using the Tools/Bad Note function in CPRS stating name of patient, SSN, date/time of note, note title, stating note was made in error.

(c) The Chief, HIM Assistant or HCAS Program Applications Specialist will change note title to erroneous.

(7) Erroneous Addendums

(a) Author of addendum adds another addendum stating addendum made in error.

(b) Author of addendum a “Bad Note” request using the steps listed above.

(c) Chief, HIM, will retract both addendums to another note title and make new note title.

r. Document Scanning

(1) Scanned documents may be linked to TIU documents and displayed with the TIU document. Scanned documents do not require an electronic signature, but are marked administratively completed.

(2) Only those documents that cannot be created in or interfaced with CPRS will be scanned.

s. Documentation:

(1) General. Health record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The health record documents the care of the patient and is an important element contributing to high quality care. The health record facilitates:

(a) The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor the patient’s health care over time;

(b) Communication and continuity of care among physicians and other health care professionals involved in the patient’s care;

(c) Accurate and timely claims review and payment;

(d) Appropriate utilization review and quality of care evaluations;

(e) Collection of data that may be useful for research and education; and

(f) Accurate coding of diagnosis and procedures performed.

(2) Documentation Principles

(a) Standards

1 Joint Commission standards regarding documentation pertinent to care and treatment records apply to both paper and electronic records.

2 The primary medium for documentation for all patient care activities within VHA is CPRS.

3 The attending physician is ultimately responsible for the accuracy of the health record for each patient under the physician’s care. The Chief of Staff (COS), or designee (equivalent), has oversight responsibility for health record timeliness, accuracy, and completion.

4 Opinions requiring medical judgment must be documented or authenticated only by medical staff members, and other individuals who have been granted such clinical privilege within their scope of practice.

5 Health care practitioners must document according to regulatory standards and generally accepted documentation practices for completeness and timeliness.

a The content of these notes must be constructive and directly related to that patient’s care.

b Communications that are not appropriate for the medical record are best handled in person, over the telephone, or via Outlook email.

c Defensive remarks, accusations or allegations, assigning blame, or otherwise “doing battle” in the medical record is inappropriate.

d The medical record is not a place to vent frustrations, whether those frustrations concern the behavior or attitude of a co-worker or the limitations of this health care system.

e Notes designed to serve as preemptive medico legal self-defense (typically entered in response to prescription denials) are inappropriate.

f Choose your words carefully and do not reveal your frustrations in your conversations or in the medical record g If you are upset, frustrated, or angry, take a ‘time out’ before writing your note.

Medical record documentation must be completed within 48 hours of the visit, not immediately.

h Before you sign your note, ask yourself if you would be proud or even comfortable having your comments projected on a screen in a court room for a jury to view. If the answer is “no”, then the entry does not belong in the medical record.

i Ask yourself if your note is inappropriately incriminating, either to the VA or to one or more coworkers. If the answer is “yes”, then the entry does not belong in the medical record.

j It is understood that unfortunate events can and do occur (i.e., dispensing the ‘wrong’ medication to a patient who becomes symptomatic). Events such as this are directly pertinent to patient care and should be documented in an objective and factual manner.

6 Health care practitioners involved with the patient’s care must enter documentation of each event of a patient’s care into the health record.

7 The practitioner who treats the patient is responsible for documenting and authenticating the care provided.

(3) Scope of Documentation

(a) The health record needs to reflect honest and candid statements; derogatory or critical comments are to be avoided. Individual employee names are not to be included in health record documentation unless the purpose is to identify practitioners for continuing care.

(b) Emphasis is placed on relevant day-to-day entries. Timely entries must be made on appropriate documents following examination and treatment as specified in VHA and facility policies.

(c) Each patient event must include or provide reference to: the chief complaint and/or reason for visit and, as appropriate, relevant history, examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; identification of appropriate risk factors; and date and legible identity of the health care professional; .

(d) The scope of documentation must be comprehensive enough to: provide continuity of care; be concise and complete; reflect any treatment for service-connected condition(s), including agent orange, ionizing radiation, military sexual trauma or external contaminants; support reported workload; and bill for services.

(4) Timeframes

(a) Each entry in the record is completed (including authentication) within 48 hours. Such policy needs to include guidance on disciplinary action when timeframes are not met.

(b) Late entries must be noted with the actual date the event occurred versus the date of documentation. NOTE: Notation as to the reason for the delay is also suggested. In CPRS, the date of entry identifies when the documentation actually occurred.

(c) Physicians and other caregivers must monitor and take appropriate action on their computerized prompts for signature, currently known as “View-Alerts.”

(d) Resident Supervision. The patient record must document adequate supervision of residents in the care of patients according to the most current VHA policy (see VHA Handbook 1400.1, for additional information).

(5) Medical Alert. Allergy or adverse reaction information must be entered in CPRS using the Allergy and Adverse Drug Reaction option. NOTE: It must be available for view in CPRS in the top right corner of every tab in the Patient Posting box and on the cover sheet in the Postings box. Allergies are also available on the cover sheet under the “Allergies/Adverse Reactions” box.

(6) Evaluation and Management (E&M) Services. For E&M services, the nature and amount of physician work and documentation varies by type of service, place of service, and the patient’s status. History, examination, and medical decision-making are the three key components of an E&M service which are considered or validated to determine the appropriate level of the E&M service. All services will follow 1997 E&M coding guidelines when assigning an E&M code.

(7) Inpatient Health Care. Health records must be complete and available for the provision of patient care according to the facility’s bylaws, but not greater than 30 calendar days from the date of discharge for inpatients. The current EHR an inpatient receiving care (if applicable) needs to be maintained intact, unless it is advantageous to separate a portion. Such separation is to be kept at the minimum required for efficient operation, and in no instance must the separated portion be located so that there would be a delay in its availability for use in an emergency by professional or administrative personnel.

(8) Emergency and Urgent Care

(a) Components. Urgent care and/or emergency documentation contain the following components:

1 Time and means of arrival.

2 Presenting problem(s), i.e., the reason for visit.

3 History and objective data relevant to the presenting problem. NOTE: When not possible for patient to give history, the reason for this is documented.

4 Assessment of the problem.

5 Treatment plan for the problem.

5 Primary and secondary diagnoses; (i.e., only those dealt with at this encounter).

7 Basis for ordering test, consult, or changes in medication.

8 Care received prior to arrival.

9 Condition at discharge.

10 Discharge instructions.

(b) Emergency Care Patient Records. Emergency care patient records will contain additional information as required by Joint Commission. Additional documentation requirements include time and means of arrival, care received prior to arrival, condition at discharge, and information regarding leaving against medical advice.

1 Emergency care rendered for humanitarian reasons to a person who is not admitted must be documented in a patient record.

2 When emergency care is provided, a copy of the record of emergency services provided must be made available to the practitioner or medical organization responsible for follow-up care.

(c) Documentation on Emergency Transfers. Documentation on emergency patient transfers to other organizations includes:

1 Reason for transfer;

2 Stability of patient;

3 Acceptance by the receiving organization;

4 Responsibility during transfer; and

5 Processing Dead on Arrival (DOA) cases. NOTE: A person who is DOA is not to be shown on hospital records either as a gain or a loss. All administrative and medical documents prepared for the person who is DOA must be filed in the person’s health record.

(d) Left Without Being Seen (LWOBS) is when a patient reports for care and leaves after triage by nursing staff and before examination by a Licensed Independent Practitioner (LIP), an LIP must review the triage documentation and determine whether an emergency existed and contact the patient when intervention must be rendered to protect the patient. In all cases, the triage note must have an addendum to state the patient left.

(9) Outpatient and/or Ambulatory Care

(a) The health care practitioner must document a pertinent progress note at the time of each ambulatory and/or outpatient care visit. Cancelled appointments or no-shows are viewable on the CPRS cover sheet.

(b) A summary and/or problem list must be initiated and maintained by the third visit by the health care practitioner and must include known significant diagnoses, conditions, pertinent past procedures, drug allergies, medications, and significant procedures performed outside VHA.

1 Entry access to the electronic problem list shall be granted only to medical staff after training. Once trained, the practitioner shall work toward historically converting each of their patient’s problem lists into an electronic problem list. Read and print access shall be provided on a need to know basis. Patient’s assigned Primary Care Provider is the ultimate custodian of the patient’s problem list.

2 Prior medical illnesses, surgeries or other clinical events that are no longer active problems shall be entered as separate problems and then inactivated.

3 The medical staff shall make all entries on the electronic problem list. New diagnoses shall be entered at the time they are made.

4 Diagnoses made by other practitioners shall be conveyed to the primary care practitioner in person, by e-mail, by telephone, or electronic progress note or consultation form. It is the prerogative of the primary care practitioner to decide if and when that diagnoses shall be entered on the electronic problem list. In the situations where the patient does not have a primary care provider - i.e. the patient is only being seen in audiology, optometry, or behavioral health services - these providers will enter their diagnosis on the problem list.

5 The narrative/comment field shall be used only to qualify the corresponding entry, not to record additional diagnoses, conditions or symptoms. Multiple entries shall not be entered into a space accorded to a single problem.

6 The electronic problem list shall not be used for recording vaccinations, screening test results, allergies, administrative labels (“has drug contract”), socio-economic status (“homeless”) or for individual patient preferences.

7 Practitioners should utilize the computer screen for review of the patient’s electronic problem list thus reducing repetitive printing of a paper copy. Should a paper copy by required, it must be scanned into the patient’s electronic record and shredded.

8 The Chief of Staff (COS) shall have overall responsibility for the policies governing the use of the electronic problem list.

9 The clinical service chiefs shall have responsibility for the implementation of the electronic problem list.

10 The medical center staff and their group managers shall have responsibility for the integrity and timely entry of diagnoses on the electronic problem list.

(c) The physician or health care practitioner must document only those diagnoses treated during an encounter or that require further treatment. An assessment as to whether continued care, on an ambulatory or outpatient basis, is required must be documented following the diagnosis.

(d) Elements for chronic disease indicators and prevention measures must be documented when appropriate.

(e) The physician must document a termination of care summary note when it has been determined that care is no longer required. The termination of care summary note must include: the condition on discharge, any patient instructions, and any relevant diagnoses, operations, and findings.

(f) Outpatient progress notes must contain the following components:

1 Presenting problem(s) (reason for visit);

2 History and subjective data relevant to the presenting problem;

3 Examination and objective data relevant to the presenting problem(s);

4 Assessment of the problem(s);

5 Treatment plan for the problem(s);

6 Diagnoses treated during an encounter or that require further treatment;

7 Reason (i.e., the medical necessity) for ordering tests, consults, or changes in medications; and

8 Follow-up treatment and patient instructions.

(10) Initial Assessments

(a) Members of the patient's care team must document initial assessments. Contents must meet the applicable Joint Commission requirements and/or specific VHA program regulations.

(b) An initial screening and/or assessment (i.e., nutrition, nursing, social work, functional, cultural, occupational and physical therapies, psychosocial, spiritual, legal, etc.) must be completed within 24 hours of admission, except for extended care, where initial screening and/or assessment is to be completed within 14 days of admission.

(c) Educational needs, preferences, abilities, and readiness to learn are assessed on admission. The education process is interdisciplinary, as appropriate, to the care plan. Documentation of education related to nutrition, nursing, and rehabilitation is required.

(11) History and Physical (H&P)

(a) A complete inpatient admission H&P examination must be available within 24 hours of admission. A history and physical examination will be performed, transcribed, signed, and filed in the medical chart of all new admissions within 24 hours of admission. Admissions to the CLC immediately following discharge from the medical center will have an interval physical examination documented in the progress note within 24 hours.

(b) An H&P, whether for admission or surgery that is over 30 calendar days old is not acceptable and a new H&P must be documented. In extended care, an annual H&P must be completed.

(c) When documenting the physical exam, a check-off format is not acceptable.

(d) When recording the history, opinions of the interviewer ordinarily are not to be recorded in the body of the history.

(e) H&P examinations must be completed by clinical staff as delineated in facility bylaws or by scope of practice.

1 Prior to Admission. A durable legible copy of a physical exam performed within 30 days prior to admission may be used in the patient’s record, if there have been no changes in the patient or if the changes are documented at the time of admission. When the patient is readmitted within 30 days for the same or a related problem, an ‘interval’ physical exam reflecting any changes may be used, provided the original exam is readily available. In either case, an interval note must be completed indicating the following:

a The H&P is still accurate;

b An appropriate assessment was completed on admission confirming that the necessity for the procedure or care is still present; and c The patient’s condition has not changed since the H&P was originally completed, or any changes are documented.

2 Prior to Surgery. An H&P must be available prior to surgery. When the H&P is done within 30 calendar days prior to surgery, the prior H&P may be used, but an interval note must be completed indicating:

a The H&P is still accurate.

b That an appropriate assessment was completed prior to surgery confirming that the necessity for the procedure is still present.

c That the patient’s condition has not changed since the H&P was originally completed, or any changes are documented.

3 Emergencies. In an emergency, when there is no time to record the complete history and physical examination, a progress note describing a brief history and appropriate physical findings and the pre-operative diagnosis must be recorded in the health record before surgery.

4 Annual Physical. When an inpatient has been hospitalized a year or longer, an annual physical examination must be completed.

5 Ambulatory Care H&P a When a patient is first admitted for VA care on an ambulatory and/or outpatient care level, a relevant history of the illness or injury and physical findings must be documented in the patient record.

b If a patient is on ambulatory and/or outpatient care status for a year, at the time of the next visit, the patient must be given an annual physical or, as applicable, an assessment of the condition for which care is authorized. The mental status of psychiatric patients must also be re-evaluated at the time of the annual physical. The examining physician must determine the comprehensiveness of the examination based upon the age, sex, and previous and current health status of the patient.

6 Dental Surgery. Qualified oral surgeons may complete the H&P of dental and oral surgery patients admitted to Dental Service. For those patients admitted primarily for dental diagnoses and treatment, a history and clinical evaluation of the dental and/or oral problem must be completed by the admitting dentist. If the admitting dentist is a board-eligible or board-certified oral surgeon with H&P privileges, that person may perform and record the medical history and physical examination for that admission. If the admitting dentist is not an oral surgeon with H&P privileges, then a physician member of the medical staff must perform and record the H&P.

7 Special Protocols a In addition to the H&P, special protocols, as prescribed in current directives, must be followed for certain patients such as former prisoners of war (POWs) and those who have alleged exposure to:

i. Nuclear tests;

ii. Ionizing radiation;

iii. Agent Orange;

iv. Environmental contaminants; and

v. Other events, chemicals, or substances as delineated by law.

b The performance of such examinations must be documented on appropriate forms and filed in the patient’s health record, or, if necessary, a record will be created.

(12) Re-assessments. Re-assessments are completed at regularly specified intervals as outlined in facility policy and related to the course of treatment, or when the patient’s physical, psychosocial, functional, or nutritional status significantly changes.

(13) Treatment Plan and/or Care Plan. An initial treatment plan, documented by the clinician, as part of the physical exam must be established on all patients within 24 hours of admission on acute care patients. In extended care, the initial treatment plan is documented within 14 days of admission; a plan of care is developed no later than 1 week after the initial assessment; i.e., within 21 days after admission. The care is planned and coordinated in a collaborative approach. Members responsible for providing care are identified in the care plan. The care plan indicates how frequently services are to be provided. Care planning recognizes advance directives and evidence of patient and/or family participation in developing and reviewing the care plan. Care plan goals are documented and the patient's response to care is evaluated when there is significant change in condition, or at least every 90 days for extended care patients.

(14) Laboratory and Imaging

(a) Order entry for laboratory tests must be completed in full, clearly identifying the: patient, location, requester, test date, special handling, and reason(s) for test.

(b) Requests for tissue examination must contain the preoperative diagnosis and a brief clinical history, which includes the reason for the examination.

(c) Requests for imaging services must contain a complete reason for the exam with a brief clinical history.

(d) Reports of imaging results must reflect: patient identity; date completed; amount of radio-pharmaceutical agents used, if applicable; specific preparation of the patient; and findings.

(15) Progress Notes

(a) General

1 Progress notes facilitate the communication among disciplines concerning the patient’s care. Members of the patient care team must document observations, progress, response to and changes in treatment, subsequent assessments of the patient’s response to care, other intervention, planned follow-up care, instructions, diagnosis and pertinent findings from ancillary tests. Progress notes must give a pertinent chronological report of the patient’s course. Progress notes may include, but are not limited to: a change in diagnoses, a change in condition, and/or a patient’s leave of absence.