MCM 14-073 Health Information Management and Patient ...



IOWA CITY DEPARTMENT OF VETERANS AFFAIRS (VA) HEALTH CARE SYSTEMIowa, City, Iowa Medical Center MemorandumDecember 12, 2014Number14-073136CHEALTH INFORMATION MANAGEMENT AND PATIENT HEALTH RECORDS1.PURPOSEa.To establish policies and procedures for managing patient health records at the Iowa City VA Health Care System (ICVAHCS). The policies and procedures will provide the basic information to ensure the ICVAHCS records are complete, accurate, timely, clinically pertinent, and readily accessible for patient care and other purposes. The health records will contain sufficient 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, legal requirements as well as billing and fiscal requirements. b.Title 38 United States Code (U.S.C.) 7304(a) is the statutory authority for the Under Secretary for Health to promulgate regulations concerning the custody, use, and preservation of records and papers of the Veterans Health Administration (VHA). POLICY a.Patient health records will be created and maintained for every individual assessed or treated at the ICVAHCS. This includes all types of patients, including those receiving community or ancillary care at VA expense, those undergoing Compensation and Pension examinations, and collateral or family members of veterans. b.ICVAHCS utilizes the medical record in an electronic format to enhance access to patient data by providers and other users. Patient health information is captured via computer based (electronic) and paper means. Paper medical record documentation is scanned into CPRS within established time frames. The electronically stored patient information is subject to the same medical and legal requirements as the handwritten information in the paper medical record.c.Historical patient health records are maintained in hard copy format and stored at a commercial storage facility and/or the Federal Records Center Upon request, the records are retrieved, scanned and sent to ICVAHCS via a secured portal. The records are then uploaded into CPRS for review by providers. d.The patient health record is the property of the ICVAHCS and is maintained for the benefit of the patient, the medical staff, and the ICVAHCS. Records will be maintained to ensure the privacy, security, and confidentiality of the information and allow prompt retrieval of the record. Records may be removed from the ICVAHCS’s jurisdiction and safekeeping only in accordance with a court order, subpoena, or statute, and only upon approval of the Chief, HIMS, facility director and/or designee. e.Protection of confidentiality and privacy of patient information shall be ensured, including, but not limited to, compliance with the Privacy Act of 1974, the Freedom of Information Act (FOIA), and the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Health records are confidential, and information contained therein will not be discussed or disclosed to unauthorized individuals. Only those persons with a need to know in pursuance of their duties will be permitted access. f.The most current standards of the Joint Commission (JC) will be followed, unless otherwise specifically stated by VA regulations or requirements as set forth by the Medical Staff Bylaws and Rules and Regulations. g.All entries will be in English. All handwritten documentation will be in either blue or black ink, legible, and will not include any abbreviations or symbols on the current ICVAHCS unapproved abbreviations list. Only approved symbols and abbreviations will be used in the health record. Symbols and abbreviations will not be used when documenting final diagnoses and procedures on discharge summaries.h.Patient health records will be completed in the time frames set by ICVAHCS policy. Please refer to Medical Staff Rules and Regulations and Attachment A for specific timeframes. i.The ICVAHCS staff may not maintain separate health records files at either their work site or office with the exception of psychotherapy notes or areas approved by VHA policy. j.VHA’s health record retention policy is 75 years. The retention policy applies to both paper and electronic records. k.The policies and procedures related to specific topics of Health Information Management and Health Records are noted in the attachments.3.DEFINITIONS.a.Addendum - Inclusion of additional information to a source document.b.Additional signer – A communication tool used to alert a clinician about information pertaining to a patient. An additional signer does not constitute a co-signature.c.Amendment – Alteration of health information by modification, correction, addition, or deletion.d.Authentication – Authentication may include written signature, written initials, or electronic signatures.puterized Patient Record System (CPRS) – The primary patient record that stores information in the Veterans Integrated and Systems Technology Architecture (VistA) or other automated system using electronic storage system. CPRS supports entry of notes and orders, rules-based order checking, and results reporting. Also integrated into CPRS is VistA imaging.f.Copayment – A type of cost sharing whereby the covered person pays a specified flat dollar amount according to the type of care provided. VA requires copayments for certain categories of veterans.g.Cosigner – The attending, staff or supervising clinician.h.Delinquent Record – An incomplete record that has not been finished within the timeframe specified in the facility’s Medical Staff Bylaws, Rules, and Regulations.i.Encounter – A professional contact between a patient and the practitioner vested with primary responsibility for diagnosing, evaluating, and/or treating the patient’s condition.j.Erroneous Entries – Entry of incorrect data within the content of a note or information entered into a wrong patient document.k.Historical visit – A mechanism to document patient/provider interaction not meeting the encounter definition in the electronic chart.l.Incomplete Record – Patient record that is missing content, reports, and/or authentications.m.Need to Know – Access to health information by authorized clinical or administrative users based on the user’s role and specific reason in the information is needed to perform his/her job function.n.Note Title – Designation given to an electronic document in CPRS or a paper form that enables a user to retrieve information from the health record.o.Scan/scanning – The capture of data via imaging/pictorial technology.p.Signer – The author of the document. q.Telephone encounter – Telephone contact between the provider and patient that includes documentation of the same appropriate elements of a face-to-face encounter, namely history and medical decision-making.4.RESPONSIBILITIES.a.The Director is responsible for ensuring adequate resources are available to maintain complete, accurate, relevant, timely, clinically pertinent, and readily accessible patient health records.b.The Chief of Staff is responsible for ensuring that health care providers, including services chiefs, assigned physicians, and other designated members of the health care team have complete, timely, appropriate, and accurate documentation in the record to identify the patient, support the diagnosis, substantiate medical care provided, record results and indicate resident supervision. The COS is responsible for medical staff compliance with this memorandum, Medical Staff Rules and Regulations, and other policies as appropriate. c.The Associate Director for Patient Care Services is responsible for ensuring patient care staff compliance with this memorandum and other policies as appropriate. d.The Chief, Health Information Management Section (HIMS), is responsible for the management of the medical record, and the control, order, and integrity of its contents. The Chief, HIMS will provide adequate support to maintain a current, available, timely, and complete medical record on all patients treated. e.The Chief, HIMS and the Privacy Officer, or designees, are responsible for amendments or corrections of the patients’ medical record and associated administrative data. f.The Medical Records Committee will assess and evaluate the quality and content of the medical record for quality of documentation, completeness, and overall adequacy as a medico-legal document. g.The CPRS Clinical Applications Coordinator (CAC) is responsible for ensuring training is available to ICVAHCS staff in using the electronic chart. h.The Compliance Officer is responsible for working with appropriate individuals to ensure compliance with the applicable laws as related to the medical record. i.The Chief Information Officer (CIO), or designee(s), is responsible for installing all software/patches related to the electronic chart. The CIO, or designee, will work closely with the ICVAHCS staff to ensure that all technical issues related to printers, scanners, and workstations are handled in a timely manner.j.All health care professionals are responsible for compiling a truthful, concise and relevant account of the patient’s health care and entering this into the patient’s medical record within the timeframes established. k.All employees are responsible for safeguarding the patient medical record, personal electronic signature codes, and computer-generated medical documents to prevent unauthorized use; for ensuring confidentiality; for preventing defacement or tampering; and for preserving the records and their contents. 5.PROCEDURES. Specific HIM topics and procedures are discussed in the attachments.6.REFERENCES. VHA Handbook 1907.01, Health Information Management Handbook; VHA Handbook 1605.2, Minimum Necessary Standard for Protected Health Information; VHA Handbook 1605.1, Privacy and Release of Information; VHA Handbook 1400.1, Resident Supervision; Joint Commission Standards Accreditation Manual, Current Edition; VHA Directive 2011-025, Closeout of Veterans Health Administration Corporate Patient Data Files Including Quarterly Inpatient Census; Iowa City VA Medical Staff Rules and Regulations, current edition; Office of Management and Business (OMB) Circular A-130, Appendix II; Iowa City VA Health Care System, MCM 11-159, Evaluation and Management Coding Policy. 7.RESCISSION. Medical Center Memorandum 12-073, Health Information Management and Patient Health Records, dated August 5, 2012./s/DAWN OXLEYActing DirectorAttachments:A.Individuals Authorized to Make Entries in the Medical RecordB.Medical Record Documentation ReferenceC.Copy and PasteD.Student DocumentationE.Erroneous Medical Record InformationF.Unapproved AbbreviationsG.Electronic Documentation EtiquetteH.Historical Visits/EncountersI.Shadow FilesJ.Scanning of Documents for the Medical RecordK.Revenue Cycle and the Electronic RecordL.Disaster/Recover Plan for Patient Health Record puter OutageN.Medical Record ReviewO.Form and Template ManagementMEDICAL RECORD DOCUMENTATION REFERENCE1.General Documentation a.The ICVAHCS will maintain complete, accurate, timely, clinically pertinent, and readily accessible health records for patient care and other purposes. The health records will contain sufficient 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, for legal requirements, and for billing and fiscal requirements. b.The primary medium for documentation of all patient care is the Computerized Patient Record System (CPRS). Other software programs may be utilized but will upload to CPRS. Paper documents will be scanned into CPRS.c.Documentation should be written in a clear, accurate, and legible manner and should support the services provided during the encounter. Rationale for all tests ordered should be documented or easily inferred. d.Progress notes not written on the same day as the encounter/visit should state, “This note is for the (insert date) visit.” Electronic notes should never be backdated. e.The documentation should support the intensity of the patient evaluation and treatment, including the thought process and complexity of the medical decision-making.f.The healthcare practitioner who treats the patient is responsible for documenting and authenticating the care provider. g.Opinions requiring medical judgment must be documented or authenticated only by supervising practitioners or others who have been granted such clinical privilege within the scope of their practice.h.The supervising practitioner or attending physician is ultimately responsible for the accuracy of the record for each patient under their care.i.Dictated notes should be signed within 24 hours of availability for signature.2.Evaluation and Management ServicesDocumentation of E&M Services must include:Chief ComplaintHistoryExamMedical Decision Making (i.e. assessment, impression, plan of care)a.Resident Supervision: The medical record must document adequate supervision of residents and other health trainees in accordance with VA policy (i.e., VHA Handbook 1400.01, Resident Supervision and VHA Handbook 1400.04, Supervision of Associated Health Trainees.b.Documentation of Diagnoses and Procedures(1)All (non-Psychiatric) Diagnoses need to include a site and etiology, when applicable and must be stated in full, without symbols or abbreviations and in accordance with the latest edition of International Classification of Disease (ICD) Clinical Modification.(2)All Psychiatric diagnoses must be stated in accordance with the latest edition of Diagnostic and Statistical Manual of Mental Disorders (DSM).(3)All operations and surgical procedures must be stated in full without symbols or abbreviations and in accordance with the latest edition of Current Procedural Terminology (CPT) and ICD-Clinical Modification (inpatients). The site involved and the procedures performed must be stated.3.Specific Documentation Requirementsa.Emergency Department(1)Documentation should be completed immediately following the visit, within 24 hours.(2)Required Documentation:Time and means of arrivalPresenting Problem(s) - reason for visit – Chief ComplaintRelevant history of illness or injuryAssessment of problemTreatment planCare received prior to arrivalBasis for ordering tests, consults or changes in medicationPrimary and Secondary diagnoses (treated during this encounter)Procedures performedCondition at DischargeDischarge Instructions(3)Patient deaths in the Emergency Department and those that are Dead on Arrival (DOA) will have the events leading to the death and the time/date of expiration documented by the physician.(4)Patients leaving Against Medical Advice (AMA) will be documented and form completed.(5)Emergency care rendered for humanitarian reasons must be documented.(6)Emergency Transfers to another facility must have the following elements documented immediately prior to transfer:Reason for transferStability of patientAcceptance by the receiving facilityResponsibility during transferb.Outpatient Records(1)Documentation should be completed immediately following the visit, within 24 hours.(2)Required DocumentationChief Complaint – reason for visitRelevant history of illness or injuryAssessment of problem(s)Treatment planBasis for ordering tests, consults or changes in medicationsExamMedical Decision MakingPrimary and Secondary diagnoses (treated during this encounter)Procedures performedFollow-upPatient instructions(3)Encounter forms will be completed on all outpatient encounters by the provider.c.Summary/Problem List(1)Initiated by the third ambulatory visit. Updated each visit for change in diagnoses, medications, treatment.(2)Primary Care Physician is the owner.(3)Required DocumentationSignificant medical diagnoses and conditionsSignificant operative and invasive proceduresAdverse and allergic drug reactionsCurrent medicationsd.Consultations(1)Consultations are requested in CPRS utilizing the consult request option.(2)Required Documentation for request:Brief description of the patient’s conditionReason for the consultationOther factors such as medication(3)Documentation to close the consult should be completed immediately following the visit, within 24 hours.(4)Electronic consults (i.e. record reviews) should be titled as such.(5)Required DocumentationSame documentation as outpatient visit. See 3b.(2).e.Inpatient Records(1)To support the VHA guidelines for workload submission, all documentation must be completed within 7 days of discharge to allow for coding of Patient Treatment File (PTF) data.(2)History and Physical (H&P)(a)Must be completed on the record within 24 hours of admission or prior to surgery. An H&P must be completed if a patient is admitted acute following an observation stay.(b)If previous H&P has been completed within 30 days, it may be used if:The H&P is still accurateAn appropriate assessment was completed on admission or at the time of the procedure confirming the need for care or that the procedure is needed.Any changes (or lack of) to the H&PThe date of the previous H&P must be documented in the note.(c)Required DocumentationRelevant past medical historyRelevant past social historyRelevant family medical historyReview of pertinent systemsPhysical ExamAssessment and treatment plan(3)Staff Admission NoteThe supervising physician must meet the patient within 24 hours of admission. Documentation must be completed by the end of the calendar day following admission.(4)Daily Progress NotesAdmission Progress note done on the day of admission must include the type of admission, chief complaint, summary of the patient’s condition, tentative or differential diagnosis and evidence of medication reconciliation.All members of the patient care team must document observations, progress, response to and changes in treatment, assessments, interventions, instructions, etc. on a daily basis as needed to ensure communication among disciplines. Progress notes should give a pertinent chronological report of the patient’s course.Supervising physicians must document evidence of resident supervision consistent with the clinical needs of the patient and the graduated level of responsibility of the resident. (5)Discharge Progress Note/Discharge Instructions(a)A discharge progress note/discharge instruction form must be completed prior to the patient discharge. Documentation must indicate when the instructions are given to the patient.(b)Required DocumentationType of dischargeDiagnosesDischarge medicationsRecommendations relative to diet, exercise, limit of disabilityCondition on dischargePlace of dispositionRecommendations for follow-upPatient educationDischarge Medication informationContact for Emergency questions(6)Death cases will include time and date of death and events leading to the death documented by the physician.(7)Documentation on patients leaving against medical advice will indicate the reason for leaving.(8)Discharge Summary(a)A discharge summary will be completed on all acute patients prior to discharge.(b)No abbreviations should be used to document the diagnosis or the surgical procedures performed.(c)Required DocumentationDate of Admission/Date of DischargesPrincipal Diagnosis – condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital. Secondary Diagnoses – complications or other diagnoses that were either confirmed or treated during this hospital stay or those chronic/existing conditions that influenced the care provided to the patient.Operations and Invasive procedures rendered during this admission.Pertinent past history and past family/social history.Pertinent points in a review of systems (including allergies or drug sensitivities)Pertinent findings of the physical examinationAbnormal findings of laboratory and radiology data.Hospital Course – include treatment receivedDischarge MedicationsDischarge instructions to include information regarding condition, and proper home care, medical follow-up, medications on discharge, diet instructions, activity or limitations, return to work date.Disposition – including condition at discharge, discharge location and follow-up care. Condition on discharge should be specific and needs to permit measurable comparison with condition on admission.(9)Do not copy and paste surgical or procedure notes, laboratory or radiology reports or other documents that are located elsewhere in CPRS into the Discharge Summary.(10)If the summary concerns a death case, the provider should document that an autopsy was or was not performed.f.Surgical Records(1)History and Physical (H&P)(2)Must be completed on the record prior to surgery.(3)If previous H&P has been completed within 30 days, it may be used if:The H&P is still accurateAn appropriate assessment was completed at the time of the procedure confirming that the procedure is needed.Any changes (or lack of) to the H&PThe date of the previous H&P must be documented in the note.(4)Required DocumentationRelevant past medical historyRelevant past social historyRelevant family medical historyReview of pertinent systemsPhysical ExamAssessment and treatment plan(5)Anesthesia Reports(a)Pre-anesthesia notes must be completed prior to anesthesia administration. (b)Pre-anesthesia notes document;Patient interview to review medical, anesthesia, and medication historiesAppropriate physical examinationReview of objective diagnostic dataAssignment of American Society of Anesthesiologists (ASA) physical statusFormulation and discussion of anesthesia plan. (6)Pre-Induction EvaluationThe patient must be re-evaluated immediately prior to induction. This re-evaluation must be documented in the Intra-operative Anesthesia Record or a progress note.(7)Post- anesthesia notes must be completed following anesthesia.(a)Post-anesthesia notes document:Patient evaluation on entering and leaving the recovery areaTime-based record of vital signs and level of consciousnessDrugs administered and their doses, type and amounts of intravenous fluids administered, including blood and blood productsUnusual events, including complicationsPost-anesthesia visitsCriteria for releasing the patient from the recovery area and the licensed practitioner responsible(8)Pre-operative Note(a)A pre-op note will be entered into the patient’s record for all cases or elective and scheduled major surgery and procedures and if circumstances permit, in cases of emergency surgery. (b)Required DocumentationFindings of the evaluationDiagnosesTreatment plan to include the procedure to be performedDiscussion with the patient and family of risks, benefits, potential complicationsAlternatives to planned surgery.(c)Informed consent must be obtained prior.(9)Post-operative Note(a)A brief post-op note will be entered into the patient’s record when the operative report is dictated.(b)Required Documentation:Pre-operative diagnosisPost-operative diagnosisProcedureSurgeonsFindingsSpecimen removedComplicationsMay also include:AnesthesiaBlood lossDrainsTourniquet timePlan(10)Operative Report/Procedure Report(a)Operative reports are required on any surgical procedure performed in the operating suite or any other high-risk procedure and/or administration of moderate or deep sedation or anesthesia.(b)Operative/Procedure reports must be entered immediately. If dictated, dictation should be completed within 24 hours. A post-operative note should be entered into CPRS (see above). (c)Required DocumentationIndication for the procedurePre-operative diagnosisName of the procedureComplete description of the procedureOperative FindingsComplicationsSpecimens removedPost-operative diagnosisNames of the attending, primary and assisting surgeonsPresence or involvement of the supervising physiciang.Observation(1)A continuation of daily progress notes is not sufficient when a Veteran changes from observation to acute inpatient status.(2)Provider is required to write a discharge order and discharge note when patient is discharged from observation. Discharge note must state discharge diagnosis.(3)When a patient is admitted acute from observation, the provider must write an order to admit to acute care.(4)When a patient is admitted acute from observation, the provider must complete an H&P. If an H&P has been done within the last 30 days, an interval H&P may be noted.h.Other: Please refer to specific MCMs regarding documentation for other specific topics including but not limited to, Seclusion and Restraints, Orders, Advance Directives, Do not Resuscitate notes, Informed Consent, etc.INDIVIDUALS AUTHORIZED TO MAKE ENTRIES IN THE MEDICAL RECORD1.POLICY: This policy establishes procedures to identify and authorize individuals who are required by their position to make administrative entries into CPRS. Only authorized staff will make entries into the patient’s medical record. All employees with access to CPRS and authorized to enter documentation in the medical record must have completed all required training, including but not limited to CPRS, Privacy, and Information Security training. a. All ICVAHCS 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. This includes, but is not limited to, anesthesiologists, audiologists, chaplains, dentists, dietitians, nurses, nurse practitioners, pharmacists, physicians, physician assistants, physical therapists, podiatrists, psychiatrists, psychologists, respiratory therapists, social workers, and speech pathologists, including students in these professions.b.Administrative staff, on a case-by-case basis, may be authorized to write administrative progress notes in the patient’s medical record. These notes will be authored and electronically signed by the administrative employee. The administrative employee will be clearly identified by their electronic signature block title. Administrative staff notes should be co-signed by appropriate, responsible party, i.e. nurse manager, provider, etc. The following procedure should be used to request approval for administrative personnel to enter a progress note:(1)The service-line director, or designee, should submit a memorandum to the Chief, HIMS, requesting approval for a named employee (s) to enter an administrative progress note. The memorandum should include justification for the request. The Chief, HIMS, will forward the request through the Medical Records Committee and Clinical Executive Board for approval. (2)The service-line director, supervisor, or designee, is responsible for monitoring the administrative notes to ensure appropriateness. c.The Chief, HIMS, and/or designee, are authorized to document in the medical record as required by VHA and other relevant regulatory and accrediting agencies, e.g., medical record amendment requests, to correct medical documentation errors, etc. d.The Service Automated Data Processing Application Coordinators (ADPAC) will assign the appropriate user class to clinical staff at the time of employment and when a change in job duties requires a different user class.e. Refer to Attachment D for policy regarding Student documentation guidelines. Other job classifications not outlined in this policy will be reviewed on a case by case basis for approval to document in the medical record. COPY AND PASTE, “Cloned Notes”, Imported Text, Objects, etc.1.POLICY: It is the policy of the Iowa City VA Health Care System to ensure accurate and concise documentation of treatment in the veterans’ medical records. The medical record is a legal document and it is expected that all entries are an accurate and complete representation of the care provided at a specific visit. The electronic functions that allow importing of text from other sources by copy and paste or use of objects are powerful tools; however, this functionality must be used with caution and according to strict and enforceable policy. Clinical, ethical, 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 collect the information at the time the visit is documented. a.Copying information from other documents in VistA, or otherwise importing information such as objects (i.e., medication or problem lists) 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. b.The following guidelines for copying text will be strictly enforced: (1)Never copy the signature block into another note. (2)Never copy data or information that identifies a health care provider as involved in care that the health care provider is not involved in. (3)Do not copy entire laboratory findings, radiology reports, and other information in the record verbatim into a note when it is not specifically addressed or clearly pertinent to the care provided. (4)The purpose of a progress note is to document the patient’s status and treatment during the current episode of care. It is never appropriate to copy a physical exam, assessment and plan or orders from a previous visit. 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. All imported data must be reviewed and corrected at the source as well as in the document if there is any inaccuracy, and it must be pertinent to the patient assessment. c.All staff documenting in the record are responsible for ensuring their documentation is unique to the specific occasion of care. Authors are liable for the content of copied items within the notes they authenticate. d.Monitoring of copy and paste incidents are performed by the Service Lines though the Medical Record Review Process and is reported to the Medical Record Committee. When violations occur, findings are reported to the Service Line Chiefs for follow-up action. e.Failure to comply with these standards may be deemed a violation of the: (1)Privacy Act requirement (5 U.S.C. Section 552a(e)(5)); or (2)Standards of Ethical Conduct for Employees of the Executive Branch (5 CFR Part 2635). f.Disciplinary action may be taken if violations of these standards are validated per VA Directive 5021. STUDENT DOCUMENTATION1.PROCEDURE: A student is an individual without a public license or certification who is supervised by a licensed and/or certified individual in the delivery of care to patients. Examples of students at the ICVAHCS includes, but is not limited to, medical students, physician assistant trainees, nursing students, and social work trainees. Rules regarding student documentation vary by discipline and the student’s level of responsibility. a.Student notes must have documentation of supervision. Supervising staff may document supervision through a separate progress note, addendum to the student’s note, or by co-signing the student’s note. In the case of medical students, it is preferable for the resident or attending to write a short addendum or separate note than to only co-sign. Supervising staff should document sufficiently to support the fact that they personally have conducted an independent evaluation of the patient. Co-signing the student’s note does not support a billable service.b.Student notes will be clearly identified by their electronic signature block title. Student notes from all disciplines will require a cosignature.c.Copy and pasted text often implies that the author obtained historical information, performed an exam, and/or documented a plan of care when he/she did not personally do it. Certain elements of the student’s documentation may be referred to, but the student’s note should not be copy and pasted into an addendum or note. d.Students must not make entries on the encounter form in CPRS; their user class prevents them from being a provider. The encounter should be completed by the resident or staff, choosing codes that support the services they provided, and identifying the staff as the primary provider. e.Medical students are not allowed to document the inpatient discharge summaries, operative reports or history and physical exams. f.The supervising practitioner or attending is ultimately responsible for the evaluation and management of the patient and for the supervision of all trainees assigned to work with him/her. While some of the day-to-day supervision of medical students may be delegated to residents, the attending retains medical-legal responsibility for the patient’s care. g.As medical students are not licensed, the documentation of an E/M service by a medical student does not constitute a billable service. The documentation of the review of systems (ROS) and/or past family/social history may be referred to by the teaching physician or resident and used to support the service. The teaching physician and/or resident cannot use the student’s documentation of history of present illness, physical exam findings, or medical decision making. These elements must be performed and documented by the teaching physician and/or resident. The documentation can be done as an addendum to the medical student note or as a standalone note. If the teaching physician refers to the student’s ROS and/or past family/social history, the teaching physician must document, “Agree with the student’s ROS and past family/social history from (specify date).” h.Documentation from other student disciplines does not support third party health insurance billing. The supervisor must do an independent patient assessment and document the care he/she provided. ERRONEOUS MEDICAL RECORD INFORMATION1.PROCEDURE: The accuracy of patient information in the Computerized Patient Record System (CPRS) is the responsibility of all users. All efforts should be taken to ensure medical record documentation is entered accurately prior to signing the documentation. Staff documenting in the record must ensure they are in the correct patient’s record for the correct episode of care. In the event that errors are identified, the following guidelines should be followed.a.Erroneously entered information will be removed and/or corrected in the patient’s health record as soon as possible. Erroneous entered information may include documentation on the wrong patient, wrong clinic visit, wrong note title, or identification of the wrong expected cosigner. Erroneous information may include scanned images. rmation entered incorrectly on paper health record notes will be corrected by drawing a single line through the incorrect information, annotating the correct information, and initialing and dating the corrected data. A note may be made to indicate why the correction was made (e.g., wrong record, or that erroneous entry was made in the patient’s medical record); and, if appropriate, the correct information added.rmation entered incorrectly into CPRS must be corrected by appropriate staff. If documentation is unsigned, it can be corrected by the author or the expected co-signer or staff with the appropriate assigned key. If documentation is signed, it is corrected by HIM staff with the appropriate assigned key. The Privacy Act of 1974 contains provisions for the amendment and correction of the medical record. The HIM Chief and/or Privacy Officer are responsible for the oversight of note corrections and for amending and retracting documents. To request corrections, the following procedure should be followed by the author: Add an electronic addendum to the note with information identifying it as erroneously entered and directing the viewer to disregard its contents.Send a VistA e-mail to G.TIU Correction with the following information:Full name of patient under whom the note was entered.Last four of the patient’s SSN of whom the note was entered.Full progress note title of the erroneously entered note.Date and time of the erroneously entered note.Indicate what corrections need to be made.The TIU Corrections group will correct the medical record information as identified in the e-mail. The associated administrative data will be reviewed and, as appropriate, corrected. UNAPPROVED ABBREVIATIONS1.PROCEDURE: No abbreviations should be used in the inpatient discharge summary, operative note diagnoses and procedure header or outpatient progress note diagnosis. The following are considered dangerous and unsafe abbreviations or dose designations and are prohibited from being used throughout the record. Refer to MCM 045 “Pharmacy Service – Medication Orders, Attachment G. AbbreviationIntended meaningCorrectionU or uUnitUse “unit”IU or I.U.International unitUse “international units”Q.O.D.Q.D. or qdEvery other dayOnce dailyUse “every other day”;Use “daily”MS, MSO4MgSO4morphine sulfate;magnesium sulfateUse “morphine sulfateUse “magnesium sulfate”ug or ?g MicrogramUse “mcg” or “microgram”QN Nightly/bedtimeWrite out.X 3 d Times three daysUse “times three days”T.I.W.Three times a weekUse “3 times per week”IN IntranasalWrite out.Trailing zero (X.0 mg)1.0 mgNever use a zero by itself after a decimal pointLack of leading zero (.X)0.5 mgUse a 0 before decimal pointELECTRONIC DOCUMENTATION ETIQUETTE1.PROCEDURE: The health record must reflect honest and candid statements regarding the care provided for a specific date of service. Documentation must support true events that occurred during the patient encounter. Electronic patient information is subject to the same medical and legal requirements as the hand-written information in the health record. Entries into CPRS must be accurate, relevant, timely, and complete. a.Progress notes not written on the same day as the encounter/visit, should state “this note is for the (insert date) visit”. Electronic notes should never be backdated. b.Documentation of needless text should be omitted. Succinct notes are more readable than verbose, lengthy notes. Laboratory results, radiology reports, and other reports should never be copied verbatim into an electronic note. c.Plagiarized information in the patient record is prohibited. Clearly indicate within the note what work that was completed during the encounter/visit and what work was performed at an earlier encounter/visit. d.Copying and pasting must be used with caution. Clinical, financial, and legal problems may result when text is copied in a manner that implies the author obtained historical information, performed an exam, and/or documented a plan of care when he/she did not personally do it. For more information on copying and pasting see Attachment C. Never copy the signature block into another note.? e.Appropriate note titles should be matched to note content and credentials of the author. Use of appropriate note titles will enhance the ability to find a note quickly and easily. f.Ensure the correct encounter location/visit location is selected prior to writing the electronic note. An incorrect encounter location can lead to the patient being billed inappropriately or impact other CPRS users’ ability to find the note quickly.g.Do not use profanity or slurs related to gender, sexual orientation, race, ethnicity or religion. Use clinical terminology to document problems or issues related to behavior, physical appearance, and attributes. The same guidance applies to any documentation in the medical or administrative records regarding a patient’s family and significant others. h.Do not make statements that are derogatory about another provider, coworker, VA facility, practice or procedure in the patient’s medical or administrative record. Use the appropriate channels to deal with these types of problems and issues.i.Individual employee names should not be included in health record documentation unless the purpose is to identify practitioners for continuing care. j.Electronic documentation should be completed within the timeframes delineated by medical center policy. Unsigned and uncosigned documentation will not be readily available for others to view.k.Do not use CPRS as a personal communication tool between providers and/or other ancillary staff. Use appropriate e-mail communication between VA personnel.l. Do not use abbreviations that others may be misinterpreted or not understood. Never use any of the abbreviations on the Medical Center Unapproved Abbreviation List. m.Do not use either the hard copy or electronic medical record for documenting information more appropriate to reports of contact. n.Do not include any identifiable information about another patient in a patient’s medical or administrative record.HISTORICAL VISITS/ENCOUNTERS1.PROCEDURE: A historical visit/encounter entry is a mechanism to document patient-to-provider or provider-to-provider interactions not meeting the encounter definition in the electronic chart. a.An encounter is between the patient and provider. Encounter documentation must minimally include the appropriate patient history, assessment, and the provider’s independent medical decision-making. b.A historical visit/encounter entry does not generate facility workload.c.Examples of historical visits/encounters include but are not limited to documenting the following:Non-face-to-face contactMaking hotel reservationsLeaving a message on an answering machineTelephone conversations with individuals other than the patientCanceling and rescheduling an appointmentNo-show notesInteractions that do not require trained medical staffA PRN chart reviewTelephone interactions with other professional staff regarding the care of the patientSummary results of outside procedure/test resultsd.Telephone calls made by the clinical staff on the same day of the visit, either during, before, or after is included as part of the visit and is reflected in the evaluation and management code. These calls should be documented as a historical telephone visit.FORM AND TEMPLATE MANAGEMENTFollowing the guidance of The Office of Management and Business Circular A-130 Appendix II, Government Paperwork Elimination Act, electronic capture and storage of patient medical information is being implemented to the fullest extent possible to enhance access to patient data by providers and support personnel. The use of paper forms is being eliminated where ever possible. 5.PROCEDURES. All internally generated medical and administrative forms or electronic shared templates that are to become part of the patient’s health record must receive approval through the facility’s Medical Records Committee prior to use.Electronic forms will be developed, revised, and maintained in cooperation with the CPRS staff and submitted to the Medical Record Committee for approval. Once approved by the Medical Record Committee, a form number will be assigned to all paper and electronic forms or templates. All requests for paper medical forms will be reviewed for possible conversion to an electronic format. Current paper forms will also be given the same review. ICVAHCS strongly encourages the use of template development as opposed to paper. Proposed forms and templates will be reviewed for legal, policy, regulatory compliance, and ease of use.All forms and templates will undergo regular review and maintenance in order to ensure that they continue to meet clinical and administrative needs. The Chief, HIMS in conjunction with the Medical Record Committee will be responsible for tracking this maintenance. All forms must contain patient identifier information (full name, date of birth, and last four digits of SSN), date of documentation, date of service and facility identifier. SCANNING OF DOCUMENTS FOR THE MEDICAL RECORDPURPOSE.??To establish policy, procedure, and responsibilities for the scanning of approved documents into the Computerized Patient Record System (CPRS) at the ICVAHCS. POLICY.??The ICVAHCS is pursuant to the goal of creating a fully electronic medical record and to improve medical care through better availability and accountability through the enhancement of VistA imaging document scanning. a.Documents must be approved for scanning by HIMS. HIMS works in conjunction with CPRS and other applicable services to determine approval.b.Only documents that cannot be created through electronic means will be considered for scanning. c.Only trained employees may scan documents into CPRS in order to provide availability of patient data for continuity of care. d.Documentation not authenticated will not be scanned into CPRS.e.Scanned medical documents are available for review via VistA Imaging Display. Training is required from CPRS in order to obtain access. Access for display of administrative documents must be requested separately. f.Scanned documents are considered confidential in nature and will be handled in accordance with established policies and VA regulations. Scanned documents are subject to the same medical and legal requirements as handwritten information in the medical record.PROCEDURE.a.Centralized scanning will be performed in HIMS except for Radiology services. HIMS is responsible for scanning paper documents generated within the ICVAHCS, fee basis records and outside non-VA records as well as numerous administrative documents.b.Inactive and historical paper records are scanned into CPRS upon request.4.RESPONSIBILITIES.a.Services are responsible for forwarding documents to be scanned by the centralized scanning unit (HIMS) on a daily basis. Documents are to be identified with full name, last four of social security number, and flagged for scanning. All fee-basis documentation must be identified as such.b.Trained and certified employees are responsible for accurately scanning the documents into CPRS.c.The supervisor of the scanning unit is responsible for ensuring that current procedures are followed. Quality checks will be conducted to ensure that trained employees are meeting criteria. REVENUE CYCLE AND THE ELECTRONIC HEALTH RECORD1.PROCEDURE: The electronic health record is an integral part of the revenue cycle. Public Law?10533 allows facilities to retain monies collected through the Medical Cost Recovery Fund. These monies are collected through two revenue streams, first-party and third-party reimbursement. Medical Record documentation must support the services performed and billed for. Documentation must be a true and factual account of the events that occurred. a.First-party reimbursement is derived from patient copayment charges. Current copayment charges are divided into four categories: medication copayment, outpatient copayment, inpatient copayment, and long-term care copayment. The outpatient copayment charges are further broken into a three-tier system: no copayment, basic copayment, and specialty copayment. The outpatient copayment charges are linked to the outpatient clinic/encounter location. b.Third-party reimbursement is derived from third-party reimbursable health insurance, workman’s compensation (federal and non-federal), tort feasor, no-fault auto, ChampVA, Tricare, interagency, and sharing agreements.c.The linkage between electronic documentation and the revenue cycle is transparent to the provider entering the note. The applicable first-party copayment charge is applied when the provider selects the encounter location when entering a progress note in CPRS. An incorrect encounter location will produce an inappropriate first-party copayment charge to the patient. d.The provider should select the appropriate note title respective to the visit or treatment provided. Incorrect note title selection will impact the ability to locate notes in a timely manner and may impact the completeness of the documentation. e.Electronic documentation will not be backdated. f.The provider must determine if the visit and/or treatment is for the patient’s adjudicated service-connected disability (adjunct and/or secondary conditions are to be marked as nonservice-connected) and/or exposure to Agent Orange, ionizing radiation, environmental contaminants, military sexual trauma, and/or conditions related to combat service. The provider will indicate the appropriate response on the outpatient encounter form. Only treatment for nonservice-connected conditions can be billed.g.Patient/provider interactions not meeting the definition of an encounter, but deemed appropriate for inclusion in the electronic medical record, will be recorded as historical visits in the electronic chart. Attachment H further defines historical visits. h. Third party insurance encounters are validated by trained HIM coding professionals for appropriate supporting documentation. Refer to ICVAHCS Medical Center Memorandum 11-159 for Evaluation and Management Coding Policy. DISASTER/RECOVERY PLAN FOR PATIENT HEALTH RECORD DOCUMENTS1.PROCEDURE: All paper health care documents will be afforded protection against defacement, damage, loss, or destruction by fire or flood or other hazards. All Health Information Management (HIM) employees will be knowledgeable of the plan and be prepared to perform duties necessary to provide full support of the plan. The following document recovery procedures will be followed. a.Fire:(1)All efforts within human possibility and staff safety will be made to keep records from fire. Personnel will not be subjected to conditions that would expose them to danger to their life or health.(2)In the event that paper medical documents sustain fire damage, the following procedure will be followed to the extent possible:(a)Damaged/destroyed documents will be identified. (b)A list of the destroyed documents will be generated and new documentation re-created as feasible. An electronic note will be placed in CPRS to document that the record was destroyed by fire and the date. (3)Partially destroyed/damaged documents will be recreated as much as possible by copying damaged pages and recreating other documents from the electronic record. An electronic note will be placed in CPRS to document the damage by the fire and the date. The copied pages will be certified and scanned into CPRS to show they are now considered the authentic document. b.Water:(1)All efforts within human possibility will be made to move the paper medical documents to an area that is unlikely to be subjected to water damage. Personnel will not be subjected to conditions that would expose them to danger to their life or health.(2)Paper medical documents will be maintained in file shelving units. Paper medical documents will not be stored on top of cabinets or on the floor.(3)In the event of water leaks or malfunctioning fire sprinklers, affected areas will be covered with plastic. Computer equipment will be shut off and covered with plastic to minimize damage after the threat to the paper documents has been minimized. (4)Should paper medical documents sustain water damage, a quick response will be required to recover their contents intact. Paper medical documents left wet for any significant length of time are at risk of unrecoverable damage due to disintegration, tearing, smearing, or mildew/mold growth. Depending on the volume of paper medical documents involved, full recovery may be realized with a local effort only, or may require more extensive measures, such as a contract with a water damage restoration company.(5)Carefully and gently pat dry as much as possible. Determine the amount of water damage sustained. Do not go through the paper medical documents at all if the pages are at risk to tear. (6)Paper medical documents dry enough to be opened may be propped in front of fans to aid in drying process. Pages should be flipped frequently so the entire record is dried.(7)Paper medical documents too wet to open should be placed in a freezer immediately. This will help prevent documents written in ink from running and becoming illegible. Once the paper medical documents are frozen solid, follow the drying process mentioned above.(8)If a large quantity of paper medical documents are wet:(a)A water damage restoration company should be contacted immediately upon discovering the damage and an emergency purchase order be secured for their services.(b)Any contract for water damage restoration services should specify the method of recovery, the time that will elapse between acquisition and return of the paper medical documents, and safeguards against breaches in confidentiality.(c)To the extent possible, a list of damaged/destroyed documents will be generated. An electronic note will be placed in CPRS to document that the record was damaged/destroyed and the date. Re-created documents will then be scanned into CPRS.c.Other Disasters: Other disasters should be handled in accordance with the Iowa?City VA Emergency Management Plan and the Business Office Emergency Operations Plan. Every effort should be made to keep all health care records safe and secured at all times during a PUTER OUTAGE 1.PROCEDURE: Refer to the CPRS Contingency/backup plan for CPRS backup plan. a.If possible, all entries into the medical record should be delayed until computer system functionality is restored. If computer is down for a limited time, providers should electronically enter the documentation and complete the encounter form once the system is restored. b.If the system is down for a lengthy time (i.e. greater than 4 hours), it is acceptable to document on approved paper forms. (1)All paper documentation must be signed and co-signed as required. Completed documentation should be sent to HIM for scanning. (2)The documents will be scanned into VistA Imaging. HIM will create notes and enter the providers as the authors, add co-signers if required and attach the note to the appropriate encounter.(3)Providers will receive a viewer alert to sign the note and complete the encounter form.d.Inpatient paper documentation should remain filed in the patient’s ward chart until discharge. Upon discharge, all inpatient paper documents should be sent to HIM.e.If there is an unplanned interruption in computer availability during the regular tour of duty (8 a.m. to 4:30 p.m.), computer users should contact the ADPAC for HIMS issues. MEDICAL RECORD REVIEW1. PURPOSE.??To define the various medical record review procedures and the process used to report findings to the Medical Records Committee (MRC).2.POLICY.??A representative sample of medical records is reviewed, on an ongoing basis, for completeness and timeliness of information, and action is taken to improve the quality and timeliness of documentation that impacts patient care. The Committee ensures that The Joint Commission criteria are reviewed and those opportunities to improve performance are identified and implemented. 3.RESPONSIBILITIES.a.It is the responsibility of the Chair of the Medical Records Committee to develop and maintain the medical record review plan and to communicate this plan to the Medical Records Committee membership.b.Quality and Performance Improvement Service is responsible for ensuring appropriate data elements are reviewed, data tracking and analysis of completed medical record reviews. In addition, this service performs Operating Room review on a monthly basis. c.Service Lines are responsible for monthly review of representative sample of medical records and for designating staff to complete the reviews. d.The Chief, HIMS, or designee, performs various reviews of medical record documentation to monitor delinquencies, close-out data and other requirements of the Joint Commission standards. Data from these reviews are tracked and trended.e.Service lines, in cooperation with Quality and Performance Improvement Service, are responsible for determining the criteria used for the care line qualitative reviews. 4. PROCEDURES.a.Concurrent Medical Record Reviews:??Provider and Nursing Documentation monthly sample sizes are based on the number of admissions/patient visits annually, divided by 12. Medicine, surgery, and behavioral health acute care/ICU admissions, Primary Care visits (including behavior health programs such as HUD/VASH and MHICM), and Community Based Outpatient Clinic visits are reviewed by designated administrative and nursing staff and sent to Quality and Performance Improvement on a monthly basis for data entry and analysis. b.Invasive Procedures in Operating Room:??Quality and Performance Improvement Section reviews the previous month’s Operating Room procedures on a continuous basis. Monthly sample size is based on the number of procedures performed annually by each surgical subspecialty, divided by 12. Data includes medical record documentation including adverse outcomes and complications.c.Sedation Procedures performed without the presents of anesthesia personnel:??These procedures are only performed in designated procedural areas of the main medical center. Records are reviewed by designated clinical staff in each area. Sample size is based on the number of procedures performed annually and sent to Quality and Performance Improvement on a monthly basis for data entry and analysis. Data includes medical record documentation including adverse outcomes and complications.d.Data Analysis and Reporting to Medical Records Committee:??Quality and Performance Improvement prepares quarterly reports (Plan, Do, Study, Act format) from the data submitted by the respective areas above. PDSA summaries are reported every other month by committee representatives from the inpatient, primary care, and procedural areas reviewed.SHADOW FILESShadow files are defined as duplicate records that are kept for the convenience of a department or healthcare provider. Shadow files can also be original data that is kept in the service area with a summary note or interpretation documented in the Computerized Patient Record System (CPRS).Joint Commission states that the medical record should contain complete information regarding the patient’s care and treatment and should promote continuity of care among providers. The hospital must have a process to track the location of all components of health records, including shadow records.To meet this standard and with the continued transition to electronic records, the need for shadow records should be limited or non-existent. Service Lines are responsible in ensuring shadow records are not maintained in their areas.If Service Lines feel that a Shadow File system is necessary for the service area to continue, approval must be granted by HIM and/or the Records Manager. A master list of shadow files will be maintained with documentation of location, security and retention guidelines. ................
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