HIMS-08 Document Scanning - Veterans Affairs



DOCUMENT SCANNING

1. PURPOSE: To establish policies, procedures, and responsibilities for scanning documents related to patient care at the VA Ann Arbor Healthcare System (VAAAHS). All supporting documents are attached and this policy applies to all organizational elements.

2. POLICY: To maintain continuous data improvement, data quality, and integrity of medical record information in the Computerized Patient Records System (CPRS) and Consolidated Health Record.

3. DEFINITION: Document imaging allows for approved paper documents to be electronically stored and viewed as part of the permanent medical record in CPRS.

4. PROCEDURE:

a. Guidelines for Requesting a New Document to Be Considered for Scanning.

1) Documents which cannot be created through conventional technology in CPRS will be scanned into the patient’s record. If a document is pending implementation in CPRS or other interfaced software through a national initiative, the document will be scanned for up to 60 days post implementation. After 60 days, the documents will be returned to the sender for transcribing into the approved electronic format. Documents will be scanned by the facility as approved by the Medical Records Committee (MRC) and the Health Administration Service (HAS) Officer.

2) Service Chiefs/Care Line Managers will complete requests for document scanning and will be responsible for compliance with the MRC guidelines.

3) Requestors will submit the Request for Document(s) to be Considered for Scanning form (Attachment A) and submit it to 136, Attention: Chief, HAS Scanning. The name of a contact and phone number should be provided to address questions at the MRC.

4) A memorandum and/or e-mail will be sent to the requestor informing the individual of the status of the request (i.e., when and where to send the documents to be scanned if the request has been approved by the MRC, or a response stating the request was denied).

5) A Request to Scan Non-VA Documents form (Attachment B) will be used when requesting the scanning of non-VA medical records into CPRS. Documents scanned will be limited to the approved list on the request form and will only include those documents that are authenticated.

6) If a clinician requests a document to be scanned that is not on the approved list (Attachment E), a justification of scanning such document(s) will be required in writing.

7) Questions should be directed to the Chief, Health Administration Service Officer at extension 55017.

b. General Guidelines for Scanning. Documents dated prior to the official national implementation date of February 1, 2011, will not be scanned; however, exceptions to this process will be left to the discretion of Chief, HAS and the MRC in collaboration with clinical providers at the facility.

c. Data Capture and Indexing.

1) Documents must be captured in DSS DocManager in a consistent manner, and the integrity of the documents must be maintained as in the paper medical record documents.

2) Documents scanned into DSS DocManager Imaging Capture will have consistent index terms to allow for proper sorting and searching of scanned documents by clinicians and administrative staff. Administrative documents/images will be captured by attaching the scanned image to the patient instead of a progress note and will be indexed with appropriate administrative indices.

3) Administrative documents scanned to the patient will be viewable by individuals who possess administrative access keys in VistA Imaging. The Clinical Application Coordinator (CAC) must be contacted to request administrative access keys.

d. Retention and Destruction of Original Paper Scanned.

1) The retention of the original source documents will be in accordance with VHA Handbook 1907.01 “Health Information Management and Health Records,” which allows the VA to destroy original source documents after scanning, but only if record retention and retrieval requirements can be met and quality control processes are in place.

2) Upon completion of scanning, the Health Information Management Section (HIMS) will maintain the original paper document until all quality control checks are completed.

3) Image files will not be deleted and will be maintained on an optical jukebox platter with backups.

e. Guidelines for Scanning Documents.

1) When a request to scan form has been received by the person scanning the document, the form should have the requestor’s signature and dated to be accepted for scanning.

2) Staff responsible for document scanning will ensure prior to scanning that all paper clips, staples, tape, and loose hanging tape are removed for the document, in addition to verifying that each document contains the patient’s name and nine-digit Social Security Number (SSN).

3) The document will be annotated in print with the patient’s identification information, as appropriate, by the scanner in black or blue ink only. The last four numbers of the patient;s SSN should be written in the top right-hand corner of the document.

4) If the patient’s demographic information cannot be located in VistA and/or CPRS due to illegible name, SSN, etc., the document will be returned to the requestor for clarification, via the Request for Scanning Clarification memorandum (Attachment F). All responses should be made within 10 calendar days. If no response is received, the image will not be scanned and will be destroyed appropriately.

5) The File Room Supervisor will maintain an excel spreadsheet, which will track the correspondence sent to the requestor, the responses received, and action, if any.

6) Once the document(s) has been scanned, the image will be checked for the overall quality and visibility of the document and for the correct or best position of the document prior to saving the image. The second quality check of the scanned document must be verified by logging into DocManager Display as part of the quality assurance check process. Both processes will be performed by the person responsible for scanning the document.

7) Documents sent to be scanned which are illegible must be re-verified by contacting the requestor. If the patient’s name is unidentifiable or if there is no response from the requestor, the document will be destroyed due to potential risks of the records being scanned into the incorrect patient record.

8) Errors involving scanned documents will be reported to the Chief, HAS or designee, who will review the record and reported error. If the image is scanned incorrectly (wrong patient, wrong image, etc.) and needs to be removed from a patient record, the Chief, HAS or designee will follow the procedures for removing scanned images and maintain a record of all images.

f. Guidelines for Monitoring Quality Assurance.

1) Staff responsible for document scanning will review each image to make sure the demographic information is correct, the image is positioned as correctly as possible, and that all pages of documents have been captured in DSS DocManager.

2) The Quality Assurance Monitoring Tool will be used for the supervisor to monitor the quality of documents scanned by his/her staff.

g. Guidelines for Reporting Quality Assurance Monitoring Results.

1) Quality Image Assurance Monitoring Requests are required to be reported to the MRC. The following information must be reported to the committee:

a) Total number of documents/images indexed for the month

b) Number of pending documents to be scanned

c) Number of errors in scanning (i.e., records indexed incorrectly)

d) Number of images requested to be deleted (by Chief, HAS only)

e) Number of progress notes deleted (by Chief, HAS only)

2) At the end of each month the section chief/supervisor is required to conduct monitors on all employees who are responsible for scanning.

3) In order to determine which patients are selected for the monitor, the Section Chief/Supervisor is to take a random sample of documents that the employees have scanned and, if there has been any errors or image deletions prior to the review, the Section Chief/Supervisor should also monitor those documents. Errors and image deletions should always be included in the Quality Image Assurance Monitors if there have been any errors.

4) The Quality Image Assurance Monitor will be reported in an Excel Spreadsheet entitled “Document Scanning QA Monitor Tool.”

h. Guidelines for Deleting Images.

1) The Chief, HAS or his/her designee(s) are the only individuals authorized to delete images from the DSS DocManager Capture and Display.

2) When an image needs to be deleted, the individual will complete the from (Attachment D) requesting the image and/or progress note be deleted. The individual must give the patient’s full name, last four of the SSN, date of the image, title of the note (if applicable), and the reason the image is to be deleted. In some cases, the physician’s signature is required if the request to delete the image is for patient information that is no longer needed by the physician(s), or if the demographic information is incorrect for that particular patient. The requestor must include date, time of note or visit, and note title in error.

3) Once an image has been deleted from the patient’s record, an addendum will be made to the scanned document note stating “There is no image associated with this note. An error was generated initially. The image has been re-indexed,” followed by the signature of the Chief, HAS or designee.

i. Scanning Contingency Plan During Computer Downtimes.

1) In the event of a scheduled computer downtime, preparations will be made in advance for scanning health records from the inpatient wards.

2) Scheduled computer downtimes of one (1) hour or less, records will be scanned the same business day if the downtime occurs before 2:00 p.m.

3) Scheduled computer downtimes of one (1) to four (4) hours, records will be scanned by the next business day.

4) Scheduled or unscheduled computer downtimes of greater than four (4) hours, records will be scanned into the medical record upon discharge.

5. RESPONSIBILITY:

a. Service Chiefs and Supervisors.

1) Ensure that all requests to scan new document types are approved by the MRC (Attachment A).

2) Ensure that all staff with scanning responsibilities are properly trained to capture documents into CPRS, using DSS DocManager or VistA Imaging Capture and VistA Imaging Display Technology.

3) Inform staff of new updates of software, patches, and changes in current policies and procedures, as communicated by the Office of Information and Technology (OI&T) and Clinical Application Coordinators (CACs).

4) Identify and report all computer-related problems to OI&T and suggest recommendations to ensure the scanning process is streamlined.

5) Maintain a list of backlogged documents to be scanned, and communicate the status to the requestors. In addition, report the results of backlogs to the MRC on a monthly basis, when appropriate.

6) Generate the DocManager or VistA Imaging Monitor report to review the productivity of each employee responsible for scanning.

7) Perform Quality Image Assurance Monitoring on a minimum of 20% of the total documents indexed each month by using the Quality Image Assurance Monitoring Tools (Attachment C) and report the results to the MRC.

b. Medical Records Committee (MRC).

1) Ensure that the integrity of the medical record is maintained with timely, legible documentation, and properly scanned images.

2) Approve appropriate new document types to be scanned by each service and maintain a list of documents scanned by the medical center (Attachment E).

3) Review Quality Assurance Monitoring results on a monthly basis.

c. All employees who are involved with document scanning.

1) Complete required training for document scanning.

2) Scan documents in a timely manner with quality and integrity.

3) Perform concurrent and retrospective quality checks of all scanned documents as outlined in the Document Scanning Reference Guide.

4) Report any problems or errors to their immediate supervisors.

5) Adhere to any new changes in policies and procedures or training methods related to document scanning and VHA Directives.

d. Clinical Application Coordinators (CACs).

1) Create and maintain document types and document titles by utilizing Text Integrated Utilities (TIU).

2) Inform services of new functionality updates and/or changes in technology (i.e., installation of new patches).

6. REFERENCES:

VHA Handbook 1907.01

VHA Handbook 1605.1

Record Control Schedule (RCS-1), Electronic Health Record

7. RESCISSION: HIMS-08 Scanning Documents into CPRS dated May 11, 2009

8. EXPIRATION: December 2014

9. FOLLOW-UP RESPONSIBILITY: Chief, Health Administration Services (136)

Robert P. McDivitt

ROBERT P. McDIVITT, FACHE/VHA-CM

Director

Department of

Veterans Affairs

Date:      

From:      

Subject: Request for Documents to Be Considered for Scanning

To: Chief, Health Administration Services (136)

1. Medical Records Committee (MRC) approval is requested for the inclusion of a document to be scanned in the Computerized Patient Record System.

2. The following information is to be requested to assist the Committee in its decision:

a. Title of the Document to be Scanned (e.g., PACU Nursing Record)

b. Where is the document originatied? (e.g., VA-generated document or outside medical document)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

c. Name and extension and/or pager number of person who will attend the MRC meeting when the document is discussed and can be prepared to answer questions, if any:

d. The rationale for wanting this document scanned is as follows (please indicate who will be responsible for scanning the document and the average number of such documents you expect to receive each week or month):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

e. The proposed document to be scanned is currently available electronically in CPRS, or is not currently available electronically in CPRS.

The Service(s) responsible for completing the document(s) are:

f. Desired date for document to begin being scanned:      

I have verified that the documents requested to be scanned are not available in CPRS.

___________________________________________________________________

Signature of Employee Preparing Request Date Service

Approved by Chief(s) of Service(s) listed in section 2(f):

_________________________________________________

_________________________________________________

_________________________________________________

g. The form meets the basic requirements for submitting a request for document scanning.

_____________________________________________________________

Chief, Health Administration Service (136) Date

Note: For questions regarding requests to scan documents, please contact the Health Administration Service at extension 55017.

Approved for Scanning

Disapproved for Scanning

Recommendation: Create CPRS template / Use existing template / Use progress note

Other: _____________________________________________________

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

| |Health Information Management Section |

|NOTE: Please attach the documents you wish to have scanned that are pertinent to the continued care of your patient and check the appropriate boxes |

|below. Only those documents approved for scanning will be scanned without further justification. Only Legible and Authenticated documents will be |

|scanned. Please initial the documents you wish to have scanned. |

| |

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

|HEALTH RECORD | Records Approved for Scanning: |

| |Advance Directive |

| |Consultations |

|To Be Completed By Clinician |Discharge Summary |

| |History & Physical |

| |Operative Reports |

|Patient Name: ______________________________ |Procedure Reports |

| |Radiology Reports |

|Social Security #____________________________ |Pathology Reports |

| |Lab Reports |

|Date Received: _____ /______ / _________ |Other |

| | |

|Outside records returned to patient. |______________________________________ |

|Records to be destroyed per preference of the patient. | |

|Outside records to be scanned in CPRS. |______________________________________ |

|MAIL FORM TO: ATTN: File Room/Scanning, 136H Ext: 55325 |

| |

|_________________________________________ |

|Print Name |

| |

|_______________________________________________________ _____ / _____ / _________ |

|Clinician’s Signature Date |

|FOR HIMS STAFF USE ONLY |

|QUALITY REVIEW SCANNING CHECKLIST |

| |

|NOTE: HIMS employees must complete this section with date performed and initials |

|Record Prep Performed ____________ |

|Date/Initials |

| |

|QUALITY RANDOM REVIEW BY SUPERVISOR |

| |

|_______________________________________________________ _____ / _____ / _________ |

|Supervisors Signature Date |

QUALITY IMAGE ASSURANCE

1. PURPOSE: All scanned images will be concurrently monitored by each individual responsible for scanning to ensure that documents scanned into the patient’s medical record are accurate for clinical and administrative use. This process will also ensure compliance and adherence to the VA Ann Arbor Healthcare System Document Scanning Policy and VHA Directive 1907.01 “Health Information Management and Health Records.”

2. PROCEDURES FOR CONDUCTING QUALITY ASSURANCE AUDITS:

a. Audits must be performed on every single document after an employee begins scanning without direct supervision, until no errors are found for three days (following initial training), or until the employee has scanned 100 documents error free.

b. The supervisor responsible for the scanning function of their service will identify 20% of the total documents scanned or a minimum of 100 documents (if 20% of documents scanned is less than 100) each month by using the Document Imaging Quality Assurance Monitor Tool. The documents will be monitored for proper and timely entry into CPRS, legibility of scanned documents, and correct entry into patient’s record.

c. All discrepancies in scanning should be followed up with the individual who scanned the document.

d. If the document is entered into an incorrect patient record, the Chief, HAS, or designee will be notified by utilizing the request to delete a document from the wrong patient’s record form and place the entry into the proper record.

e. If the document is entered into the wrong title, the Chief, HAS, or designee will be notified for proper action.

f. If the document is illegible, the document will not be scanned.

g. Results of audits will be reported to the Medical Records Committee and Management of Information Committee on a monthly basis by the Chief, HAS.

h. When consistent problems are identified, focused reviews will be conducted that look at a higher volume of scanned documents. The errors must be investigated to determine the cause, scope, and seriousness, and an action plan must be implemented and reported to the Medical Records Committee.

[pic]

Department of

Veterans Affairs

Date:      

From:      

Subject: Request for Image(s) and Progress Note(s) to be deleted from Record

To: Chief, Health Administration Service (136)

**Supervisors will be contacted by the Chief, HIMS, regarding requests. Requests for image deletion will not be completed if an explanation is not provided as required below.**

Prior to submission of this form, an addendum must be added to the progress note. (e.g., “An incorrect image has been attached to this patient’s record” or “a duplicate image has been scanned to this progress note in error”).

Images will be deleted from a patient’s record for the following reasons only:

1) Document was scanned into the wrong patient’s record

2) Image is illegible

3) Duplicate document has been scanned to the patient’s record more than one time

4) Physician requests for information to be deleted

Please briefly explain the reason why this image should be deleted (including the patient’s full name, social security number, date image was scanned, and title of progress note):

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________ ___/___/_____ _________________________

Signature of Employee Date Service

__________________________________ ___/___/_____ _________________________

Signature of Service Chief Date Service

__________________________________________________ ___/___/_____

Signature of Chief, HAS or designee Date

WARNING!

[pic]

An Image Has Been Removed from this Patient’s Record by:

Type Here Individual’s Name Who Will Delete Image

The image for “Type Patient’s Last Name Here – Last 4

” was scanned into the incorrect patient by Type Name of Scanner Here on Type Date of Image Here.

______________________________ _______

Signature of Chief, HIMS or designee Date

|SERVICE |PHASE |ROOM |LIST OF DOCUMENTS TO BE SCANNED |NOTE TITLE/PROCEDURE |

|  | | | | |

|MED RECORDS (2) |I |BB70 |Outside Clinical Records non-Fee Basis |Outside Records/Tests |

|  | | |Outside Clinical Records Fee Basis |Outside Records/Tests |

|  | |BB30 ROI |ROI Authorization Form |Administrative Document |

|  | | |Subpoenas |Administrative Document |

|  | | |Disability Determinations |Administrative Document |

|ADMITTING |II |C116 |Means Test 10-10F and 10-10EZ |Administrative Document |

|  | | |Other administrative documents |Administrative Document |

|SOCIAL WORK |I |B159a |Outpatient Advance Directives |Advanced Directive note |

|  | | |Mammogram report |Mammogram Report Consult note |

|PSYCHOLOGY |I |B717 8N |Inpatient Advance Directives |Advanced Directive note |

|ER |I |ER |Mammogram report |Mammogram Report Consult note |

|  | | |Consent forms |Physician's urgent care note |

|  | | |ER Flow Sheet (needs revision) |Physician's urgent care note |

|OPTHALMOLOGY |I |BB70 |Request/Consent for Anesthesia |Informed Consent note, |

| | | | |Ophthalmology Outpatient note or |

| | | | |Ophthalmology Inpatient note |

|  | | |Cornea size chart from Compusion device |Ophthalmology Outpatient or |

| | | | |Inpatient note |

|  | | |Retinal Field Chart |Ophthalmology Outpatient or |

| | | | |Inpatient note |

|  | | |Ophthalmology Progress Note |Ophthalmology Outpatient or |

| | | | |Inpatient note |

|SERVICE |PHASE |ROOM |LIST OF DOCUMENTS TO BE SCANNED |NOTE TITLE/PROCEDURE |

|SURGERY PACU |I |PACU E520 |Perianesthesia Record |Anesthesia-Postoperative note |

|  | | |Anesthesia Record |Anesthesia-Postoperative note |

|  | | |Preanesthesia Evaluation |Anesthesia-Postoperative note |

|  | | |Request for Anesthesia/Procedure |Informed Consent note or |

| | | | |Anesthesia-Postoperative note |

|UROLOGY |I |E105 STA 8 |Request for Anesthesia/Procedure |Urology Procedure note |

|PSYCHIATRY MH |I |EB07 |DD214 Military form for PCT clinic patients |PCT Assessment note |

|  | | |Consent for Treatment (Antabuse) |Psych Clinic Note |

|  | | |Release of Information |Psych Clinic Note |

|  | | |Outside Medical Records |Outside Records/Tests |

|PSYCHIATRY HOMELESS PROGRAM |II |EB06A and |HCHV Intake, Form X |Psy Evaluation note |

| | |TOPC | | |

|  | | |HCHV Discharge, Form D |Psychi Progress Note |

|PULMONARY |II |D722 |PTF results/graphs |PFT Results Note |

|  | | |Bronc procedure consent |Pulmonary Broncoscopy |

|ENDOSCOPY |I |D707 |Endoscopy procedure consent |Endoscopy procedure note |

|CARDIOLOGY |I |7th fl COU |Procedure consent form |Cardiology procedure/note |

|  | | |Conscious sedation form |Cardiology procedure/note |

|HEMODIALYSIS |II |A363 | | |

|AUDIOLOGY |I |A133 |Audiograms |Audiology Diagnostic note |

|  | | |Strip Chart printouts-Tympanometry results |Audiology Hearing Aid note |

|  | | |ENG, ABR, OAE tracings |Audiology Diagnostic note |

|  | | |Grand Rapids CBOC exams |Historical visit to Audiology note |

|  | | |Case History form |Audiology Consult/Diagnostic note |

|  | | |Acoustic Admittance |Audiology Consult/Diagnostic note |

| | | |Fitting Follow-Up |Hearing Aid Note |

|SERVICE |PHASE |ROOM |LIST OF DOCUMENTS TO BE SCANNED |NOTE TITLE/PROCEDURE |

|DENTAL |II |B247 |Dental Anesthesia Consent |Oral Surgery Outpatient note |

|  | | |Periodontal Chart |Dental Outpatient note |

|  | | |Procedure/conscious sedation flowsheet |Oral Surgery Outpatient note |

|  | | |Oral Examination finding and treatment |Dental Outpatient note |

| | | |recommendations | |

|NEUROLOGY |II | | | |

|LAB |II |C316 |Consent for Fine Needle Aspirate |Fine Needle Aspirate note |

|BLOOD BLANK |II |Wards | | |

|  | | | | |

|PM&R |II |Station 10 |Consents |Clinical Warning Note |

| |II |Station 10 |Narcotics Agreement |Clinical Warning Note |

|PT/PM&R | | |Cardiac Rehab flow sheets, EKG strip, Heart |request new note title--Physical |

| | | |Rate, Telemetry, Pulseox |Therapy Discharge Summary note |

|  | | |Inpat/Outpat Wound Patient Tracing |In or Outpatient Physical Therapy |

| | | | |note |

|OCCUPATIONAL THERAPY | | | | |

|RADIOLOGY |II | |Outside Radiology results |Radiology package accession |

|  | | |Radiology procedure consents |Post procedure note |

|  | | |Radiology Flowsheets |Post procedure note |

|RADIATION ONCOLOGY | | |Procedure consent form |Rad/Onc Consult |

|INPATIENT WARDS (6) |II |5E | | |

|RESEARCH |II |G19A |Consent to participate in research study |Research Enrollment Clinical |

| | | | |Warning |

|PRIMARY CARE Station 6 |II | |Outside Medical Records |Outside Medical Record |

| | | | |Non-Fee-basis; Outside Medical |

| | | | |Record Fee-Basis |

|  | | |Consents |Pending |

|MCCR | | |Explanation of Benefits (EOB) |Administrative Document |

|SERVICE |PHASE |ROOM |LIST OF DOCUMENTS TO BE SCANNED |NOTE TITLE/PROCEDURE |

|NUCLEAR MED | | |Consents |Procedure Note |

|DERMATOLOGY | | |Consents |Dermatology Outpatient Note |

|TOLEDO (3) |II | |Outside Medical Records |Outside Medical Record |

| | | | |Non-Fee-basis; Outside Medical |

| | | | |Record Fee-Basis |

|  | | |Consents |Procedure Note |

|  | | |Request for Auth. To Release Info. |Administrative Document |

|  | | |Mammogram |Mammogram Report Consult note |

|JACKSON CBOC |II | |Outside Medical Records |Outside Medical Records |

|  | | |Consent forms |Procedure note |

|FLINT CBOC |II | |Outside Medical Records |Outside Medical Records |

|  | | |Joint Injection Procedure Consent |Clinic visit note |

|  | | |Incision and Drainage Procedure Consent |Clinic visit note |

Department of

Veterans Affairs

Date:      

From: File Room Scanning (136H)

Subject: Request for Scanning Clarification

To:      

3. This memo is to request clarification regarding illegible and/or missing patient demographic information sent for scanning.

4. A pre-scanning review has been conducted on this document and the following has been determined:

❑ Legible correct patient name is needed to correctly identify patient

❑ Legible correct patient SSN is needed to correctly identify patient with the same name.

❑ Incorrect spelling of patient name, no record found in CPRS

❑ Correct document note title is needed

❑ CPRS Note is unsigned

❑ Illegible documents submitted

❑ Partial documents submitted

NOTE: Records will be processed upon receipt within 10 working days of the above information.

____________________________________________ ___/___/ ______

Signature of File Clerk Date

Please return form and documents to:

File Room/Scanning 136

Policy Memorandum Tracking Sheet

|Title of Policy |Policy Number |

|Document Scanning |HIMS-08 |

|Author of Policy |Submission Date |

|Mary Myers |August 31, 2011 |

|Department |Routing Symbol |Phone # |

|Health Administration Services |136 |55017 |

|Items rescinded by this policy |

|Policy Memorandum HIMS-08 dated May 11, 2009 |

|Reason for changes or creation of this policy |

|Approval by Service Chief or Supervisor |

| |

|_______________________________________________ _____________________________ |

|Signature Date |

| |

|____ This policy describes current practice. |

| |

|____ This is a new procedure; implementation training will be provided by: |

| |

|_____________________________________________________________ |

|Name(s) of individual(s) |

|Symbol |Concurrence Signatures |Date |

|AFGE |Union Representative – David Maier |11/2/2011 |

|00Q |Quality Management – JoEllyn Smith |11/15/11 |

|11 |Chief of Staff – Assumed | |

|14A |ACOS, Education – Assumed | |

|001 |Associate Director – Randall E. Ritter |11/13/11 |

|00B |Assistant Director – Ginny L. Creasman, Pharm.D. |11/7/2011 |

|118 |AD, Patient Care Services – Assumed | |

|OI&T |Facility Chief Information Officer – Assumed | |

|HIMS |Health Information Management Officer – Assumed | |

|136 |Health Administration Officer – Mary Myers |8/31/2011 |

| | | |

| | | |

|Remarks |

| |

| |

-----------------------

Memorandum

Ann Arbor VA Healthcare System

Memorandum

Memorandum

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