VA Roseburg HCS



DOCUMENTATION OF MEDICAL RECORDS1. PURPOSE: The purpose of this VA Roseburg Healthcare System (VARHS) Medical Center Memorandum (MCM) is to outline and define policy and procedures relative to preparation, completion, and maintenance of patients'/residents’ medical record documentation.2. POLICY: The medical record (paper or electronic) shall contain sufficient and accurately recorded information to serve as the basis for patient/resident care. It is the policy of VARHS to meet the standards of The Joint Commission, Department of Veterans Affairs regulations, and VARHS Medical Staff By-Laws.Any clinical or administrative person, who, as part of their position, is required to document patient/resident information for care or communication, is authorized to make an entry in the medical record.All entries into the medical record must be authenticated (signed). Signatures must include the printed name, title, and credentials (if applicable) of the signer. Co-signature is required for those individuals whose privileges or scope of practice does not allow independent documentation, including all students and volunteers, by appropriate supervising staff members. All medical record entries by Residents will meet the documentation requirements as outlined by VHA Handbook 1400.1, Resident Supervision.3. DEFINITIONS: Licensed Independent Pracitioner (LIP) is a Physician (Doctor of Osteopathy or Doctor of Medicine), Dentist (Doctor of Dental Surgery or Doctor of Dental Medicine), Advanced Practice Registered Nurse (APRN) (includes Certified Registered Nurse Anesthetists,Clinical Nurse Specialists, and Nurse Practitioners), Optometrist, Podiatrist, Doctor of Pharmacy (PharmD), Clinical Pharmacist, or Psychologist. See VARHS Medical Staff Bylaws for additional information regarding privileging. 4. RESPONSIBILITIES: The Chief of Staff and the Associate Director of Patient Care Services are responsible for ensuring the timely completion of medical records and the accuracy and completeness of medical record documentation.The Chief, Health Information Management (HIM), or designee, will be responsible for the administrative processing of medical records, to include quantitative and qualitative analysis and coding of diagnoses and operations. The Medical Records Committee will be responsible for overseeing the review of medical record documentation and advising the Executive Committee of the Medical Staff at least quarterly about the status of the completion of records and problems with medical record documentation.Clinical staff Documentation: Clinical staff are required to document, accurately and completely, in the Computerized Patient Record System (CPRS) any and all information pertinent to episodes of direct patient/resident care as required by external regulatory agencies, Veterans Health Administration regulations, and facility policies. This includes: A significant change in patient/resident condition, level of care, or a change in the treatment plan;Clear and concise documentation relating to a patient/resident discharging from VARHS medical care Against Medical Advice (AMA);When there is a clinical encounter;Significant abnormal diagnostic or consult reports are received;A patient/resident is placed in physical restraints;A patient exhibits high risk behavior in the judgment of the clinician; orAs outlined in local unit policies.Documentation Errors: Clinical staff are responsible for promptly reporting all documentation errors in accordance with VARHS MCM 653-136-001, Management of Information, Attachments A and C. 5. PROCEDURES:Inpatient Admissions or ObservationsHistory and Physical DocumentationAll patients/residents admitted or placed in a bed section, excluding lodgers and Community Living Center (CLC) residents, require a History and Physical (H&P) examination be performed, documented, and authenticated within twenty-four (24) hours of admission in accordance with MCM 1219, Patient Assessment/Reassessment.H&P examination notes for residents admitted to VARHS CLC must be completed within forty-eight (48) hours of admission. H&P examinations performed, documented, and or authenticated greater than twenty-four (24) hours after an admission to the hospital, forty-eight (48) hours after admission to the CLC facilities, will be considered delinquent. If a patient/resident is readmitted within 30 days of the most recently documented H&P for the same or a related condition, an interval history and physical examination must be documented. The examination documentation must reflect any subsequent changes (as applicable). The Attending provider, or designee, is responsible for the History and Physical examination, admission note, and the initial treatment plan for patients/residents admitted during normal duty hours (those hours not covered by the Medical Officer of the Day (MOD)). For off-tour hours (those hours covered by MODs), the ADMITTING provider is responsible for this documentation. All admissions will be assigned to an inpatient attending provider according to established procedure. If the admitting provider fails to perform the History and Physical, the assigned attending practitioner shall take the required corrective action.The responsible supervisor is required to ensure that all admissions in the respective units have the History and Physical examination completed. If not, he/she shall take the required corrective action.H&P Prior to Surgery: All surgery patients must have documentation authored by the performing surgeon or anesthesia provider (Anesthesiologist or CRNA), which clearly indicates review and update, as applicable, of an H&P note dated less than thirty (30) days prior to the scheduled surgery date. If there is no H&P examination documented within thirty (30) days or less prior to the date of surgery/procedure, a new H&P examination must be performed, and documented by the performing surgeon, prior to performing the operation/procedure.H&P notes must document the following examination and assessment components: Chief complaintPast medical history History of Present illness(HPI)/Details of present illnessSocial HistoryFamily History Allergy work upMedication History Physical ExamAssessment Plan Progress Notes and Operative/Procedure NotesComputerized Patient Records System (CPRS) electronic progress notes will be used for the recording of pertinent, meaningful observations and information concerning the care of the patient/resident. Progress notes will give a pertinent chronological report of the patient's/resident’s condition and treatment provided during an episode of care. Progress notes will also reflect any changes in condition, patient's/resident’s response to treatment, and updates of the treatment plan. Documentation will not be started prior to the patient/resident presenting/being presented for care. “Prepping” of patient care documentation is not acceptable for direct patient/resident care staff.Documentation will comply with all applicable regulatory standards to ensure medical record legibility, accuracy, as well as facilitate quality patient care. Progress notes, procedure notes, and consultation documentation must contain whenever applicable, the following components:Chief complaint;HPI;Review of Systems;Physical Examination;Assessment;Plan/Treatment; andFor consultations, an indication that the patient’s health record was reviewed.Progress notes, procedure notes, and consultations must be authored /dictated and authenticated (signed) as soon as possible after patient care services have been provided to NOT exceed forty-eight (48) hours, to ensure quality patient care. If a note is dictated, a brief note indicating that the note has been dictated must be authored and signed by the dictating clinician as soon as possible after dictation, but no later than close of business on the date of dictation. In the event of an extenuating circumstance (sudden illness, emergency, etc) which prevents the Provider from authoring/dictating and signing their documentation within forty-eight (48) hours of the patient care episode, the individual is responsible for notifying their immediate supervisor and completing the documentation immediately upon their return. When authoring/dictating a note in excess of forty-eight (48) hours from the time that the patient care was provided, the note is considered to be a late entry and the following line (or a similar line to this effect) must be added to the beginning of the late note to indicate such: “This note is being authored as a late entry. Patient was seen for care on [insert encounter/appointment date and time]”. Progress notes will be recorded as appropriate for the condition of the patient; sufficient to permit continuity of care and transfer-ability; and dated and signed by the appropriate clinical staff. See MCM 1219, Assessment and Reassessment, for expected frequency of rmed Consent: All medical records will include evidence of informed consent for any invasive procedure or treatment for which it is appropriate, as outlined in MCM 653-000-003, Informed Consent Process.Non-OR reports for invasive procedures not involving anesthesia or moderate sedation will be documented in CPRS immediately following the procedure.Operative reports will be documented immediately following surgery involving anesthesia or moderate sedation. All dictated operative reports must be signed as soon as possible after being transcribed, to not exceed twenty-four (24) hours. When the operative report has been dictated, a brief note must be authored and signed immediately after surgery, indicating that the note has been dictated before the close of business on the day of the encounter. The content of the operative report will include at minimum:Indication for the procedure;Operative findings; Technical procedure used; Specimens removed; Post-operative diagnosis; Name(s) of the supervising practitioner, Primary surgeon, and assistants; andPresence and/or involvement of the supervising practitioner. A post-operative progress note must be dictated or directly entered into the patient’s health record by the performing surgeon immediately following surgery and before the patient is transferred to the next level of care. The post-operative note must include: pre-operative diagnosis, post-operative diagnosis, technical procedures used, surgeons, findings, specimens removed, and complications.Discharge SummariesAll discharges (including interfacility transfers and discharge by death) require a discharge order, to be entered by the Attending Provider. The discharge summary must be prepared for all releases from VHA care, including deaths. Transfers to other levels of care (i.e., VHA Mental Health Residential Rehabilitation Treatment Program (MH RRTP), VHA CLC, or other VHA health care facilities), must be documented by a discharge summary.An addendum is required to be added to the discharge summary if it is signed forty-eight (48) hours prior to discharge or if there is a significant change in the patient’s/residents condition. Responsibility for the preparation of the discharge summary and for its content rests exclusively with the member of the medical staff having primary care responsibility for the patient.The completed (signed) summary must be available for viewing in CPRS on the date of discharge for regular inpatient discharges, within twenty-four (24) hours of death or irregular discharge for inpatients, and within 72 hours for Community Living Center (CLC) residents.Discharge Summary Content – Discharge summaries must include the following components: Name of the member of the medical staff responsible for patient’s/resident’s care and the primary physician, if applicable;Principal diagnosis – This is the condition established after study to be chiefly responsible for the admission of the patient/resident to the hospital for care;Additional diagnoses – A additional diagnoses treated should listed in the order of importance/significance;Psychiatric diagnoses (when applicable); Note: If the patient’s/resident’s mental health condition, including but not limited to psychosis or cognitive disorder, may affect their competence to handle VA funds, an evaluation must be done to ascertain competency status and the findings must be documented.Operations and surgical procedures; Pertinent past medical history;Pertinent points in a review of systems (including allergies or drug sensitivities);Pertinent findings of the laboratory and radiological data; Pertinent findings of the physical examination, particularly abnormalities;Brief course in hospital stay to include treatment received and condition on discharge; NOTE: Condition must be more specific than “improved” and needs to permit measurable comparison with condition on admission.Condition of wound, if applicable;Place of disposition, i.e., home, CLC, etc;Discharge instructions to patient or responsible other, to include:Information regarding condition or proper home care;Medical follow-up. NOTE: If a private physician, state the name if possible;Medications on discharge;Diet instructions;Activity or limitations; andSpecific date to return to work; NOTE: State if a period of convalescence is required, if retired, or if any of this is to be determined at a later date. If the summary concerns a death case, there must be a statement that an autopsy was or was not performed.Outpatient/Ambulatory Care Documentation: Whenever applicable, in addition to the documentation guidelines set forth in paragraphs 4 and 5a of this MCM, the following guidelines relating to proper patient/resident care documentation must be followed: Each ambulatory care visit will be documented in CPRS.Each ambulatory mental health visit will be documented in CPRS. When a patient/resident is initially admitted to VA care for ambulatory/outpatient services, he/she will be given an initial evaluation as specified in MCM 1219. The following actions will be taken: Health care needs will be prioritized and met in a manner appropriate to immediate and preventive health needs. Current medications, including non-VA prescriptions, over-the-counter medications, and herbal preparations, will be entered in CPRS. The allergy status of the patient/resident will be entered via CPRS into the Adverse Reaction/Allergy Tracking package. A patient/resident education assessment will be completed.An electronic Problem List including diagnoses and past surgeries will be initiated by the time of the third visit and updated as necessary upon subsequent outpatient/ambulatory care visits, in accordance with Joint Commission Standards.The primary care provider is ultimately responsible for the accuracy of the problem list entries concerning medical problems and known past surgeries. Where applicable, a patient/resident may have a mental health provider who is ultimately responsible for the accuracy of the problem list entries pertaining to mental health.Mental Health Treatment Plan: For each psychiatric ambulatory/outpatient care patient/resident, an overall treatment plan will be initiated at the time of the first ambulatory/outpatient care visit and completed by the third visit.Standards for documenting Home Based Primary Care encounters may differ as specified in the program's Standard Operating Procedure.Downtime Procedures: In the event of CPRS Downtime refer to MCM 653-011-011, Verbal, Telephone, and Protocol Orders, and the Service Specific contingency plans.Emergency Room Encounter Documentation: Whenever applicable, in addition to the documentation guidelines set forth in paragraphs 4, 5a, and 5b of this MCM, the following guidelines relating to proper patient/resident care documentation must be followed: Emergency Room documentation must have the following minimum components: Time and means of arrival;Presenting problem(s), i.e., the reason for visit;History and objective data relevant to the presenting problem. When not possible for patient to give history, the reason for this must be documented; Assessment of the problem; Primary and secondary diagnoses; i.e., only those dealt with at this encounter; Treatment plan for the problem to include basis for ordering tests, consults, or changes in medication;Documentation of care received prior to arrival when known;Condition at discharge; andFor Dead on Arrival (DOA) cases or deaths in the Emergency Department, the time and date when the patient expired and the events leading to the death must be recorded by the attending provider.When a patient reports for care and leaves after triage by nursing staff and before examination by an 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 be added to state that the patient/resident left.Emergency care rendered for humanitarian reasons to a person who is not admitted must be documented in CPRS.Documentation on emergency patient transfers to other organizations must include the following: Reason for transfer;Stability of patient;Acceptance by the receiving organization; andResponsibility during transfer.Encounter Form Completion An encounter form is a numerical interpretation of the signed progress note and should not be completed prior to documentation completion.A primary Provider must be indicated on all encounter forms as this individual is responsible for the timely completion of the encounter form. The primary Provider is the LIP primarily responsible for the patient’s/resident’s care during the encounter/admission. Only an LIP may be the primary Provider for an encounter, unless the encounter is associated with a non-LIP clinic (nursing clinic, social worker clinic, etc). All outpatient encounter forms must be completed as soon as possible by the primary treating Provider following a completed episode of care, to not exceed forty-eight (48) hours. Failure to complete encounter forms in forty-eight (48) hours can lead to administrative actions.All emergency care encounter forms must be completed by the primary treating Provider, as soon as possible following a completed episode of care, to not exceed twenty-four (24) hours. Failure to complete encounter forms in twenty-four (24) hours can lead to administrative actionsVARHS does not currently require clinicians to complete encounter forms for inpatient admissions. At which time inpatient encounter form completion is required, this memorandum will be updated in compliance with federal regulation. Students/Interns The Supervising LIP is responsible verifying and co-signing all documentation entered into CPRS by the student/intern. The Supervising LIP must author a separate note (minus the student/intern) documenting the care that was provided during the directly supervised encounter for workload and revenue purposes. Any interactions performed by the student/intern outside of the direct supervision of the assigned LIP are not considered a valid encounter for workload or revenue purposes. A service specific non-count clinic should be created in order to capture these encounters. Students/interns should only be allowed to interact with Veterans without direct supervision as allowed by state and federal regulations. For Resident supervision requirements see VARHS MCM 653-011-015, Resident Supervision.Additional Signers The additional signers feature is to be utilized to ensure that team members are made aware of relevant documentation to ensure continuity of care for a shared patient. The additional signer feature is used for the purpose of notification, not authentication, unlike the Co-Signer feature. An additional signer(s) is not responsible for the content of the note to which they are added. Authors will only identify additional signers directly involved in care for the patient. Examples:A Hospitalist may add a PCP to a discharge summary for one of their mutually assigned patients.A Consultant may add the referring provider to a note to convey specific recommendations. The consultant does NOT need to add the referring provider or PCP when completing a consult (i.e. using a Consult-Specialty note title). These staff automatically receive alerts when consults are completed.Authors will not identify individuals who do not have a direct care relationship with the patient (e.g. adding the Chief of Staff regarding an administrative concern).A consult should be used if the author is requesting the opinion of another provider.6. REFERENCES:VHA Handbook 1907.1, Health Information Management and Health Records, (August 25, 2006)VARHS Medical Staff Bylaws 7. RESCISSIONS: MCM 2812, Use of Abbreviations (June 2011)MCM 2811, Documentation of Medical Records (June 2010)(Original signed copy on file in QM office)Carol S. Bogedain, FACHEDirectorAttachments: Forms and Template Creation and ManagementUse of AbbreviationsList of Prohibited AbbreviationsFORMS AND TEMPLATE CREATION AND MANAGEMENTPURPOSE: To delineate the process for requesting and approving forms and templates that will be a part of the Consolidated Health Record (CHR) and establish a centralized mechanism to oversee and track the development and maintenance of forms and templates used in the CHR at VA Roseburg Healthcare System (VARHS).POLICY:All forms or medical center templates that are to be included in the health record must be approved by the VARHS Medical Records Committee (MRC).Requests for revisions or new medical record documents will be sent via email to the Microsoft Outlook email group, VHAROS-Medical Records Committee.Revisions to an existing form or template must be approved by MRC.All paper overprints that are to be filed/scanned into the Health Record must have an overprint (OP) number assigned to them and be overprinted on an SF (Standard Form) or VAF (VA Form).Electronic templates will be the medium of choice. Paper forms should only be used when documentation by electronic template is not possible. Documentation on paper forms is to be limited to those documents where an electronic solution has not been identified or are unavailable (i.e. computer down-time).When creating or revising paper forms, the use of the social security number as an identifier (either in full or part), will be avoided whenever possible. GuidelinesLocal forms or templates will not be initiated when an existing national or VISN standardized form or template can be used for the same purpose.Local forms or templates initiated at VARHS are to be for essential needs and must be appropriately coordinated and approved.Reviews may be conducted by the MRC to ensure that obsolete or unnecessary health record paper forms and templates are eliminated.Revision of paper forms or electronic templates within one year is discouraged unless there are regulatory or accrediting requirements to support such revisions.RESPONSIBILITY:Service Line/Departmental Managers are responsible for ensuring that all templates and/or paper forms utilized are approved in accordance with this medical center memorandum. Medical Records Committee:Coordinates review processes of electronic and OP paper templates;Approves electronic templates;Approves new paper OP forms;Coordinates a routine review of paper forms;Coordinates assignment of OP number;Collaborates with Materials Management to maintain a log of all forms approved for use in the CHR; andMaintains hard copies of all paper forms approved for use in the CHR.The initiating requestor is responsible for:Ensuring that necessary supervisory approval(s) for the affected service line(s)/department(s) is obtained prior to submitting to the form/template request to the MRC; Drafting an electronic version of the proposed paper form and/or template and submitting it to the Medical Records Committee, via the VHAROS-Medical Records Committee Microsoft Outlook email group, for review; Attending committee meetings where the proposed form or template is on the agenda, when requested;Issuing/providing end user notification, training, or other education that users of the form or template will need;Providing paper forms, if approved, to Materials Management for duplication and storage when appropriate; andBringing any request for revisions, when needed, to the attention of the MRC for approval.PROCEDURES:Note Titles - The initiating requestor will confer with the Clinical Applications Coordinator(s) (CAC) to identify an appropriate title from the national standard note title list. He/She will then send an email to the MRC via the VHAROS-Medical Records Committee Microsoft Outlook email group. The email will include the requested titles as well as the justification/reason for the request and intended users. Note Templates - The initiating requestor will confer with the Clinical Applications Coordinator to prepare a draft of the proposed template. He/She will then send an email with the draft attached to the MRC via the VHAROS-Medical Records Committee Microsoft Outlook email group. The email will include the justification/reason for the request, if the template is to be attached to a note title, the type of template (e.g. boilerplate, reminder dialog), and intended users.Consults - The initiating requestor will prepare a draft of the proposed consult request and associated order menus. He/She will then send an email with the draft attached to the MRC via the VHAROS-Medical Records Committee Microsoft Outlook email group. The email will include the justification/reason for the request and intended users.Consents - The initiating requestor will prepare a draft of the proposed consent. He/She will then send an email with the draft attached to the MRC via the VHAROS-Medical Records Committee Microsoft Outlook email group. The email will include the justification/reason for the request, where the consent form should be filed in iMed Consent, and intended users.The MRC will review and issue a determination within four weeks (20 working days) of receiving requests. Approvals will be submitted to the initiating requestor and CACs. Urgent requests should be identified as such in the initial email request and must include an explanation of the urgency. If determined to be an urgent need by the MRC, the requests will be reviewed and a determination will be made as soon as possible, to not exceed two weeks (10 working days).Determinations will be recorded by the MRC at least quarterly. The form/template will be reviewed by the MRC for content as prescribed by VHA Handbook 1907.1, Health Information Management and Health Records, or other authoritative source. The initiating requestor should submit any applicable supporting documentation or references, such as a VHA Directive or national accreditation standards requirement, along with the request for approval.If the form/template requires major revision after review and approval by the MRC, the revised draft of the form/template must be re-presented to the MRC for approval. REFERENCES:VHA Handbook 1907.01, Health Information Management and Health Records, (September 2012)MP-1, Part II, Chapter 4, Forms ManagementVHA Directive 2009-021, Data Entry Requirement for Administrative Data (April 2009)RCS 10-1, Records Control Schedule.USE OF ABBREVIATIONSPURPOSE: To promote patient safety and effective medical record documentation practices at VA Roseburg Healthcare System (VARHS) by defining policies related to the use of shorthand, to include abbreviations, in Consolidated Health Record (CHR) documentation.POLICY:To ensure CHR documentation is accurately interpreted by its various audiences, and thereby reducing the risk of injury to patients due to interpretation error, it is the policy of VARHS to discourage the use of shorthand, to include abbreviations, in the CHR. When abbreviations are utilizing the following guidelines will be followed:Abbreviations will be use judiciously; Abbreviations ONLY from the most recent edition of Stedman’s Abbreviations, Acronyms, and Symbols Medical Abbreviations will be utilized; andAbbreviations will be readily understandable to mean only one thing in the context used. The symbols and abbreviations listed in Attachment C of this MCM are PROHIBITED FOR USE at any time in the CHR. These prohibited abbreviations may not be used, even if they are included in abbreviation resources or commonly used elsewhere.This includes, but is not limited to, pre-printed forms and handwritten medication prescriptions.RESPONSIBILITY: Service Chiefs are responsible for: Ensuring that staff are educated regarding the appropriate use of abbreviations in the CHR; Establishing a process where periodic reviews are performed to ensure that correct documentation process are used; andTaking corrective action if prohibited abbreviations are found to be utilized. The Medical Record Committee is responsible for the periodic review of clinical documentation and preprinted forms that are utilized for the use of the prohibited abbreviations listed in Attachment C.REFERENCES: The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH)Stedman’s Abbreviations, Acronyms, and Symbols Medical Abbreviations – Fifth Edition PROHIBITED ABBREVIATIONSSetItemAbbreviationPotential ProblemPreferred Term1.1.U (for unit)?Mistaken as zero, four or cc. Write "unit"2.2.IU (for international unit)?Mistaken as IV (intravenous) or 10 (ten).Write "international unit"3.?3.4.Q.D., Q.O.D.(Latin abbreviation for once daily and every other day)?Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I". Write "daily" and "every other day"4.?5.6.Trailing zero (X.0 mg), Lack of leading zero (.X mg)Decimal point is missed.Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)?5.?7.8.9.MSMSO4MgSO4?Confused for one another. Can mean morphine sulfate or magnesium sulfate.Write "morphine sulfate" or "magnesium sulfate6.10.?g (for microgram)Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose.?Write "mcg"7.11.T.I.W. (for three times a week)Mistaken for three times a day or twice weekly resulting in an overdose.Write "3 times weekly" or "three times weekly"8.12.c.c. (for cubic centimeter)?Mistaken for U (units) when poorly written.Write "ml" for milliliters ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download