Document Scanning Policy - Veterans Affairs



DEPARTMENT OF VETERANS AFFAIRS

NORTH TEXAS HEALTH CARE SYSTEM

January 20, 2015

549/001D

VANTHCS MEMORANDUM NO. 001D-03

DOCUMENT SCANNING POLICY

1. PURPOSE:

The purpose of this memorandum is to define policies, objectives, and responsibilities for scanning of internal and external\outside documents, the integrity of data capture and document pickups across the facility related to patient care for VA North Texas Health Care System (VANTHCS).

2. POLICY:

It is the policy of VANTHCS to be committed to creating an environment that promotes and fosters the use of the Computerized Patient Record System (CPRS) by defining policies, objectives, and responsibilities for scanning of documents related to patient care.

3. PROCEDURES:

a. All documents must contain sufficient information to identify the patient, i.e., patient name, date of birth, and social security number.

b. Any document for which a template cannot be created in CPRS will be scanned. The Health Information Advisory Committee (HIAC) or its equivalent will approve the documents to be scanned into CPRS. For those forms and documents standard to VA, the Health Informatics Team will develop a standardized naming convention for note titles. Administrative documents/images are viewable only in Veterans Integrated System Technology Application (VistA) Imaging

c. Scanned documents will be made available to clinicians within CPRS and can be accessed via the Tools menu. Examples of scanned documents may include advance directives, progress notes containing drawings, non-VA health records, etc.

d. A scanned image will be annotated by a blue icon next to the corresponding date in the Progress Notes tab, and with the words (scanned document) directly following the corresponding progress note title of the document. The following statement will appear in the narrative section, providing instructions on how to access the scanned document via VistA Imaging:

******SCANNED DOCUMENT ATTACHED TO THIS NOTE******

To view the scanned documents related to this patient:

Click on Tools

Click on VistA Imaging Display

Click on appropriate scanned document by referring to the short description of the image within the VistA Imaging Abstract window (double check date/title of note)

e. All administrative and clinical documentation will have the words (Scanned Document) directly following the corresponding title of the document. All administrative and clinical documentation can be viewed through CPRS via the Tools menu by selecting VistA Imaging Display.

f. In accordance with the VHA Records Control Schedule RCS 10-1, all hardcopy/paper source documents (originals) of scanned images will be destroyed after verification of accurate entry into CPRS has been identified. VistA Imaging Display will be accessed to check the accuracy of linkage, indexing and integrity of the document to the record. Once this is done the electronic copy becomes the original copy (Attachment A).

g. The following non-VA documents will be scanned into CPRS once received by the scanning department: DD214’s, non-VA advanced directives or medical Power of Attorney documents.

h. All other non-VA medical documents received in the scanning department, will first be sent to the clinician\provider for approval of entry into CPRS and must be accompanied with a ‘Request to Scan non-VA Documents’ form (Attachment A). The form will be filed out as follows:

(1) The name of the facility from which the documentation originated should be identified near the top of the form.

(2) The correct Patient Identification Information (PII) will be properly identified in the designated area at the bottom of the form.

(3) All the different types of documents will be marked\identified on the form. If the document type is not listed the selections marked as “Other” will be used to further identify the document.

(4) The clinician\provider will legibly print, sign and annotate the date the form and documentation was approved by the clinician.

i. The clinician\provider will provide these documents to scanning staff by direct receipt from clinician\provider or staff, routing through inter-office mail, E-fax and/or pick-up rounds completed by scanning staff daily.

j. In order to scan all documents in a timely manner, scanning support staff will perform daily loose document pick-up rounds twice a day Monday through Friday during regular business hours.

k. Loose documents will be picked up in designated areas across the facility.

l. Chief, Health Information Management Service (HIMS) or File Unit Supervisor should be notified by the clinical service of the development of new areas\services that will produce patient documentation. This will allow HIMS management to establish a designated area within the service for loose documentation pick-up.

m. All scanning will take place in a centralized location within HIMS.

n. Decentralized scanning will be considered for approval by the Chief, HIMS based on the urgency of the reports for patient care.

o. The integrity of data capture on all documents will be identified by the signature of the provider to uphold the integrity of the document. This must be available before scanning

p. External documents that were requested or sent to VA without signature may be scanned when accompanied by a ”Request to Scan non-VA Document” form filed out by a VA physician.

4. RESPONSIBILITIES:

a. Staff responsible for scanning will ensure that each document contains at least two patient identifiers: full name: social security number: and/or date of birth.

b. Chief, HIMS will ensure all requests for scanned documents are approved by VANTHCS, HIAC. Supervisor of File Unit staff are responsible for monitoring image quality and for ensuring that all staff with scanning responsibilities are properly trained.

c. File Unit Scanning Clerks will ensure that scanned documents are attached to the appropriate progress note title (VA documents) or consult title (non-VA documents) and will perform a 100% quality control and concurrent review of the document capture session to also ensure readability and it is retrievable.

d. Training will include a procedure for scanning documents when there is no corresponding note title (a progress note will have to be created before scanning can be completed in these instances). All centralized File Unit Scanning Clerks are authorized to create administrative progress notes for the scanning purposes.

e. HIMS team is responsible for developing and approving standardized progress note titles (VA documents) and consult titles (non-VA documents) used for scanning documents.

f. Supervisor, File Unit and File Unit Scanning Clerks will ensure documents scanned into CPRS are indexed in a timely manner. Information regarding backlogs due to equipment failure, vacancies, or computer downtime will be reported to the HIAC to include a plan of action to address the backlog.

g. Chief, HIMS or File Unit Supervisor will be the only VANTHCS staff with the functionality to delete a scanned image. All errors involving scanned images will be reported to the Chief, HIMS or designee.

h. Appropriately identified individuals will be responsible for the return to patients of inaccurate documents with a letter of explanation and blank form for completion and return.

5. REFERENCES: VHA Handbook 1907.01Health Information M; The Joint Commission Manual Information Management Standards; VHA Record Control Schedule 10-1.

6. RESCISSION: VANTHCS Memorandum No. 04D-03, dated

August 16, 2012.

Jeffery L. Milligan

Director

Attachments

Distribution: A

Attachment A

QUALITY ASSURANCE PROCEDURES

1. PURPOSE:

All document images will be monitored according to VHA Handbook 1907.01 to ensure documents scanned into the patients' medical record are accurate for clinical/administrative use. This process will also ensure compliance and adherence to VANTHCS document scanning policy.

2. PROCEDURES:

a. Quality control audits must be performed on every scanned document to ensure readable and retrievable. Paper health records or administrative documents will be retained for five days after scanning to allow for completion of the quality assurance review by the Supervisor or the designee. If no inconsistencies or problems with scanning are found, the documents will be destroyed. Identified errors found will be corrected.

b. The Supervisor or Lead will identify a sample of at least 30% of each individual who scans documents per month for review using the Image Quality Assurance Monitor tool (Attachment C).

c. The documents will be reviewed for proper linkage to the Veterans’ record, proper indexing and integrity of the document scanned into CPRS audits will be done on a weekly basis.

d. All discrepancies consisting of proper linkage to the Veterans’ record, indexing and integrity will be documented and followed up with the individual who scanned the document. The individual will access the record and rescan the document correctly and will then notify the designated staff who will then delete the inappropriate document. This will be done immediately. Remedial training will be conducted to correct the deficiencies.

e. These discrepancies will be identified directly or by the Image Quality Assurance Monitor. The Image Quality Assurance Monitor will identify discrepancies as follows:

(1) Linkage to the record consists of the document being attached to the correct Admin, Medical or Clinical Association.

(2) Indexing consists of attaching the correct PII, note title, date of procedure and short description of document scanned.

(3) Integrity of Data Capture consists of the image quality (readability), document positioning, and if there is a duplication of images scanned.

f. Results of audits are sent to the Chief, HIMS or designee on a monthly basis. The results of the audits will be reported to HIAC on a monthly basis.

g. All scanned documents can be viewed in VistA Imaging Display that can be accessed on the Tools menu in CPRS.

h. An illegible original will be stamped "illegible original" prior to scanning if there is no way to correct the clarity of the document using the scanning software that uploads the image into CPRS.

i. When an accurate determination of identification cannot be made by scanning staff, the document will be returned to the originating service for further identification and accompanied by the Document Declared Unidentifiable form (Attachment D).

j. Errors involving scanned documents will be report to the Chief, HIMS or designee. Chief, HIMS will assign a designee who will be allotted access to deleting images from the patients’ record. Chief, HIMS or designee will review the record and report error(s). If the image is scanned incorrectly (wrong patient, wrong image, etc.) and needs to be deleted from a patient record, the Chief or designee will follow this procedure:

(1) Print the incorrect image via VISTA Imaging Display.

(2) The designee will provide a reason for the deletion being made will be electronically saved in VistA Imaging Display. The deleted image(s) will only be visible to Office of Information Technology (OIT) staff or designated personnel.

(3) Delete the incorrect image from the record where it appears in error.

(4) Scan the printed copy of the image into the correct patient record.

k. These processes will be reviewed as new functionalities are provided in VistA Imaging. Implementation of the VistA Imaging initiative is an ongoing project encompassing procedural and staff changes as well as software changes and enhancements.

3. RESPONSIBILITIES:

a. Chief, HIMS is responsible for reporting quality assurance monitors to HIAC on a monthly basis.

b. Chief, HIMS, File Unit Supervisor or designee is responsible for ensuring the integrity of the medical record is maintained with timely and legible documentation.

c. File Unit Supervisor or designee is responsible for:

(1) Performing quality monitors on documents scanned by Scanning Technicians or Scanning Support staff.

(2) Ensuring Scanning Support staff is properly trained on all applications used to capture documents images in CPRS.

(3) Performing quality monitors on documents scanned by other appropriate staff.

(4) Ensuring other appropriate staff is properly trained to capture document images in CPRS.

|[pic] |REQUEST TO SCAN NON-VA DOCUMENTS |

|Please attach the documents you wish to have scanned and check the appropriate boxes. We will only scan the documents that you attach to this checklist. Paper|

|records are no longer filed. |

| |

|FROM (Name of Hospital, HMO, or Doctor where care was provided)________________________________________ |

|TEXT DOCUMENTS |2) DIAGNOSTIC TESTING |2a) DIAGNOSTIC TESTING (continued) |

|Hospital Discharge Summary | | |

|History & Physical |Pathology reports | |

|Emergency Room Notes |Radiology Reports |EMG |

|Progress Notes |Mammogram |Nerve Conduction Study |

|Medication List |Nuclear Medicine Scans |Pulmonary Function Test |

|Chiropractic Notes |EKG |Allergy Testing |

|Consult Reports |Cardiac Stress Test |Other__________________ |

|Correspondence (type) |Echocardiograms | |

|_______________________ |EEG |____________________ |

|________________________ | | |

|Other: | | |

|3) OPERATIONS | 4) PROCEDURES |

| | |

|Operation Report |Endoscopy |

|Anesthesia Record |Colonoscopy |

|Open Heart Perfusion Data |Sigmoidoscopy |

|Myocardial Preservation Data Sheet |Cardiac Catheterization |

|Pacemaker Device Report |PTCA Report |

| |Other: ______________________________ |

| |_____________________________________ |

| |

| |

|__________________________________________ __________________________________________________ |

|Clinician’s Signature/ Date Clinician’s Printed Name and Title/Date |

|Patient’s First and Last Name |Patient’s SSN |

| |

| |

| |

|IMAGE QUALITY ASSURANCE MONITOR |

| |

| |

| |

| |

|  |LINKAGE |INDEXING |INTEGRITY |  |

1 |Patient Full Name |Last 4 (SSN) |Document PN or Consult Title |Date Scanned |Admin Record |Medical Record |Clinical Association |Correct Patient |Correct Note Title Entered |Correct Short Description |Correct Date |Image Quality |Doc Position Correctly |Duplicate Image Scanned |Date of Review |(errors) Totals | |2 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |3 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |4 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |5 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |6 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |7 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |8 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |9 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |10 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |11 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |12 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |13 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |14 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |15 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |16 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |17 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |18 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |19 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |20 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | |

HEALTH INFORMATION MANAGEMENT SERVICE (HIMS)

SCANNING DEPARTMENT

MAIL ROUTE 001H

ROOM BA-301A1 EXT 71351

DOCUMENT DECLARED UNIDENTIFIABLE FOR SCANNING

The HIMS-Scanning Department has received documents from an employee, physician, or section in your service for scanning. In order to accurately scan documents in a timely manner for viewing by authorized personnel, the documents must be identified properly with legible patient identifiers\labels, and the date the procedure took place. If any of this information is not present, it prohibits the documentation from being incorporated into VistA Imaging and CPRS.

It has been determined by our Scanning Support staff at VANTHCS Dallas facility that the attached documents have been rejected for scanning and returned for corrections to their respectable services\sections for the following selected reason(s):

__Patient’s name is missing

__Patient’s social security number is missing

__Date of procedure is missing

__Patient\Physician’s signature is missing

__Patient’s identifiers do not match (name\ss#)

__Multiple patients exist. Provide full\correct Patient Identifiable Information (PII)

__Handwritten patient name/social security number is illegible.

Once the corrections have been made please hand carry or send through inter-office mail addressed to our department. Routing information is provided above.

Please feel free to call us if you have any questions about this action.

Thank you,

Scanning Support Supervisor

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Department of Veterans Affairs

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