S02 - Attch - D.11. Corrective Action for Delinquent Medical Records.pdf

Department of Veterans Affairs Policy COS-006 Nebraska-Western Iowa Health Care System July 21, 2017

CORRECTIVE ACTION FOR DELINQUENT MEDICAL RECORDS

1. PURPOSE:

To establish policy and procedure approved by the Executive Committee of the Medical Staff (XCOM) regarding corrective action when credentialed healthcare providers permitted to document Veteran care in the medical record are delinquent in completing medical records of patients under their care.

2. POLICY:

Medical records are to be completed in a timely fashion. When records are not completed within a time frame established by the medical staff and/or the Nebraska- Western Iowa Health Care System (NWIHCS) Chief of Staff, corrective action will be initiated. Unless specified in NWI policy BUSOF-017 Medical Record Documentation, medical records are considered overdue at 7 days beyond the service date and delinquent at 30 days beyond the service date. Corrective measures will not be applied until the practitioner at risk has been formally notified by the Service Chief of the impending action and has been given an opportunity to comply with all requirements governing completion of medical records.

3. RESPONSIBILITIES:

a. Healthcare providers are responsible for completing medical records in a timely fashion.

b. Service Chiefs are responsible for monitoring and ensuring timely medical record completion by healthcare providers in their Service.

c. The Chief of Staff monitors provider staff medical record completion and takes administrative action against providers with delinquent medical records.

4. PROCEDURES:

a. The Health Information Management Section (Medical Records) of the Business Office will notify the Service Chief and Administrative Officer of the Service Chief when deficiencies or delinquencies are identified.

b. Healthcare providers will be notified by the Service Chief or his/her representative when they have deficient or delinquent inpatient or outpatient medical records.

c. When a healthcare provider has deficient medical records and fails to correct the deficiencies within 30 calendar days, he/she shall be subject to sanctions unless extenuating circumstances exist which precluded rectifying the deficiencies in a timely fashion.

d. Service Chiefs will notify the healthcare provider in writing when they have record(s) more than 30 days overdue. The provider will be given 10 days from receipt of notification to correct all delinquencies before sanctions take effect.

e. After the 10-day warning period, the Service Chief will impose an appropriate sanction limiting the provider’s access to the operating room, procedure areas, and/or clinic. Where applicable, the Chairman of the provider’s medical school department will be notified in writing of the sanction. The sanction may be immediately revoked upon record completion.

For NWI VA employees, additional disciplinary actions may also be applied:

1) Verbal Counseling

2) Written Admonishment

3) Written Counseling

f. If the provider fails to correct the delinquent record by the 45th day, the Chief of

Staff will take steps to:

1) Administratively Suspend the provider’s privileges

2) Notify the affiliate Dean of the action, if applicable

g. Failure to correct delinquent records following the suspense may result in the revocation of the provider's NWI medical staff appointment and a reportable privileging action to the NPDB or, for non-privileged providers, progressive personnel action up to and including termination.

5. REFERENCES:

• Medical Record Documentation Policy BUSOF-017, December 6, 2016

• Health Information Management and Health Records VHA Handbook 1907.01 March

19, 2015

6. RESCISSION:

Policy COS-006 dated June 14, 2014

7. FOLLOW-UP RESPONSIBILITY:

Chief of Staff

9. NEEDED CONCURRENCES:

BUSINESS OFFICE

CLINIC MANAGER-LIN

CLINIC MANAGER-GI

ASSOCIATE DIRECTOR

CHIEF OF STAFF

AFGE 2219 (LN)

AFGE 2270 (OM)

AFGE 2601 (GI)

HUMAN RESOURCES

HEALTH INFORMATION-OM

XCOM

10. KEY WORDS:

DELINQUENT MEDICAL RECORDS

SANCTIONS

RECORDS

LATE

PROCESSING

/es/

DAVID A. WILLIAMS, M.D.

Chief of Staff

/es/

B. DON BURMAN, MHA

Director

APPENDIX: A

DEFINITIONS:

Deficient:

a. H&P not dictated within 24 hours of inpatient/observation admissions

b. Long Term Care H&P not dictated within 72 hours of admission to CLC

c. Discharge Summary not dictated at the time of discharge, with the exception of irregular discharge or completion of an autopsy.

d. Operation Report not dictated the same day of procedure

e. The inpatient record not complete (authenticated) not complete within 30 days after discharge.

f. Outpatient progress notes not complete within 7 calendar days (ensures patient data capture for performance measures and other corporate reporting needs).

Delinquent:

a) Inpatient record is deficient if not complete (authenticated) within 14-29 days after discharge

b) Outpatient progress notes are deficient if not complete (authenticated) within 48 hours of encounter with patient