T-1
Department of Veterans Affairs VHA HANDBOOK 1907.07
Veterans Health Administration Transmittal Sheet
Washington, DC 20420 May 12, 2016
MANAGEMENT OF HEALTH RECORDS FILE ROOM AND SCANNING
1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Handbook
provides basic procedures for managing the health record File Room and Scanning
activities within a Health Information Management (HIM) Department.
2. SUMMARY OF CONTENTS: This new VHA Handbook establishes guidance for
managing the health record File Room and Scanning function(s).
3. RELATED DIRECTIVES: VHA Handbook 1907.01, Health Information Management
and Health Records, and Records Control Schedule (RCS) 10-1.
4. RESPONSIBLE OFFICE: The Office of the Assistant Deputy Under Secretary for
Health for Informatics and Analytics (10P2C) is responsible for the contents of the
Handbook. Questions may be referred to 217-649-3691.
5. RESCISSIONS: None.
6. RECERTIFICATION. This VHA Handbook is scheduled for recertification on or
before the last day of May 2021.
David J. Shulkin, M.D.
Under Secretary for Health
DISTRIBUTION: Emailed to the VHA Publications Distribution List on 05/12/2016.
May 12, 2016 VHA HANDBOOK 1907.07
i
CONTENTS
MANAGEMENT OF HEALTH RECORDS FILE ROOM AND SCANNING
1. PURPOSE ................................................................................................. 1
2. BACKGROUND ......................................................................................... 1
3. SCOPE ....................................................................................................... 1
4. RESPONSIBILITIES .................................................................................. 1
5. SCANNING REQUIREMENTS .................................................................. 3
6. RESCISSION OF ADVANCE DIRECTIVES .............................................. 3
7. FILE ROOM AND SCANNING STAFF AND STRUCTURE ....................... 3
8. FILE ROOM RECORD PROCESSES ....................................................... 4
9. SHADOW RECORDS ................................................................................ 5
10. CLOSING THE FILE ROOM .................................................................... 5
11. PERMANENT TRANSFER OF PAPER RECORDS ................................ 6
12. EXTERNAL SOURCE DOCUMENTS ...................................................... 6
13. LOCATOR CARDS ................................................................................. 7
14. ADVANCE DIRECTIVES ......................................................................... 7
15. DOCUMENT SCANNING PROCEDURES .............................................. 8
16. GUIDELINES ON IMAGE DELETION ..................................................... 9
17. DESTRUCTION ....................................................................................... 9
18. SCANNING AND FILE ROOM CONTINGENCY PLANS DURING
COMPUTER DOWNTIME .............................................................. 10
19. DOCUMENT SCANNING TRAINING .................................................... 10
20. CONDUCTING QUALITY ASSURANCE MONITORS ........................... 10
21. GUIDELINES FOR REPORTING QUALITY ASSURANCE MONITOR
RESULTS ...................................................................................... 12
22. DOCUMENT SCANNING STAFFING .................................................... 12
23. DOCUMENT SCANNING JOB SERIES AND PERFORMANCE
DESCRIPTION (PD) ...................................................................... 12
24. DOCUMENT SCANNING PRODUCTIVITY ........................................... 12
25. REFERENCES ...................................................................................... 13
May 12, 2016 VHA HANDBOOK 1907.07
1
MANAGEMENT OF HEALTH RECORDS FILE ROOM AND SCANNING
1. PURPOSE
This Veterans Health Administration (VHA) Handbook provides procedures for
managing the scope and operations of the health record File Room and Scanning
activities. AUTHORITY: 38 U.S.C. 305, 5723(d), 5727(9); 44 U.S.C. 3102(1).
2. BACKGROUND
File Room and Scanning activities include functions relative to providing complete,
accurate, clinically pertinent and readily accessible patient health records to support the
care provided to the patient. Scanning involves activities to digitize documents and data
utilizing imaging or pictorial technology available in the patient health record. This
Handbook outlines the standardized processes and procedures regarding creation,
maintenance, management, processing, and expected quality monitors.
3. SCOPE
The File Room and Scanning section(s) at a facility provide(s) customer service to
the users of the health record by retrieving and delivering health records that meet all
applicable Federal laws, rules and regulations as well as The Joint Commission
standards for provision of health records. The File Room and/or Scanning section(s)
are staffed with, and supervised by, qualified, trained personnel. File Room and
Scanning staff members are considered experienced once they have had the
opportunity to review all available training aids, guides, handbooks, and complete
hands-on training to develop a thorough understanding of File Room and Scanning
activities. The time frame may vary by facility but at a minimum developing qualified
staff will require 6 months of supervised training and experience.
4. RESPONSIBILITIES
a.
VA Medical Facility Director. The VA medical facility Director, or designee, is
responsible for establishing policies and processes that are in place ensuring:
(1)
All duties associated with health record filing and scanning are done in a timely
manner and in accordance with existing VA and National Archives and Records
Administration statutes, regulations, and policies.
(2)
Health record File Room and Scanning activities are under the supervision of a
qualified professional who is well-versed in all aspects of health record File Room
management and Scanning activities, preferably the Chief, Health Information
Management (HIM), or designee.
b.
Chief, Health Information Management. The Chief, HIM or designated File
Room/Scanning Supervisor is responsible for the following File Room and Scanning
activities when included in the HIM Section:
VHA HANDBOOK 1907.07 May 12, 2016
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(1)
Developing and monitoring processes to assure all File Room and Scanning
activities are completed in an accurate and timely manner.
(2)
Overseeing VistA Imaging document scanning.
(3)
Ensuring that record tracking software is utilized to its full potential if paper
records are in use.
(4)
Developing standard operating procedures or other reference documents
outlining the responsibilities for both the File Room and Scanning staff members,
making them available to all involved in these processes, and monitoring compliance.
(5)
Complying with mandated records management requirements, including timely
and accurate record retirements.
(6)
Ensuring that a system is in place to identify and prioritize expedited requests for
both active and retired/archived health records.
(7)
Ensuring that all requests for new scanning titles are approved by the Medical
Records Committee (MRC) or equivalent.
(8)
Ensuring that all staff members with scanning responsibilities are properly trained
to accurately capture documents into Computerized Patient Record System (CPRS),
using VistA Imaging Capture and VistA Imaging Display Technology, DocManager and
Fee Basis Claims System (FBCS).
(9)
Identifying, requesting, or reporting the need for new scanning equipment or
reporting all computer related problems.
(10)
Suggesting recommendations for streamlined documentation processes, such as
using electronic record processes vs. paper processes.
(11)
Assuring that quality assurance (QA) monitors are in place for the File Room and
Scanning functions as detailed in this Handbook.
(12)
Deleting incorrect document images and attaching to correct progress note.
(13)
Establishing, monitoring, and concurring on all related policies/procedures for the
document scanning and File Room management efforts of the facility.
(14)
Changing titles of rescinded advance directives to watermark the image,
pursuant to the requirements of VHA Handbook 1004.02, Advance Care Planning and
Management of Advance Directives, or successor policy.
(15)
Keeping File Room and Scanning staff members informed of the latest updates
to VA and VHA policies, rules, and regulations involving File Room and Scanning;
providing staff members awareness and access to updated or new resources, and
validating staff participation in all applicable training.
May 12, 2016 VHA HANDBOOK 1907.07
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(16)
Overseeing all File Room and Scanning activities to ensure they are completed
according to established time standards. NOTE: In the rare circumstance when this is
impossible for good cause, a delay notification will be provided to the person requesting
the health record or assistance with the scanned document.
(17)
Managing day-to-day File Room and Scanning operations.
(18)
Monitoring daily reports for pending health record requests for paper health
records and documents waiting scanning for section productivity.
(19)
Establishing a priority system for completion of health record requests and
document scanning, including expedited requests, to ensure all requests are completed
within required timeframes.
5. SCANNING REQUIREMENTS
a.
Completing required training for document scanning;
b.
Scanning documents in a timely manner with quality and integrity;
c.
Ensuring all scanned documents are indexed correctly and attached to the
appropriate patient, progress note title.
d.
Performing and documenting concurrent and retrospective quality checks of all
scanned documents as outlined in the Quality Monitor section 20 of this policy;.
e.
Reporting any problems or errors to their immediate supervisor and/or designee,
and informing Office of Information & Technology and HIM as appropriate. Examples of
these include, but are not limited to, issues with software functionality, or errors
identified with scanned images; and
f.
Adhering to any new changes in policies, procedures or training methods related
to document scanning, VistA imaging, VA policies and FBCS.
6. RESCISSION OF ADVANCE DIRECTIVES
a.
Advance Directive progress notes are displayed via postings in CPRS as
specified in VHA Handbook 1004.02.
b.
Alerting Chief, HIM or designee of the need to rescind Advance Directives in
CPRS in order for it to be marked “Rescinded” in VistA Imaging or other approved
imaging system.
7. FILE ROOM AND SCANNING STAFF AND STRUCTURE
a.
It is recommended that File Room management and Scanning oversight
operations be centralized under a single supervisor who provides services to the main
facility, on-site clinics and any medical facility associated Community Based Outpatient
VHA HANDBOOK 1907.07 May 12, 2016
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Clinics (CBOCs). The ability to safeguard the Veteran’s privacy must be considered
when designing the File Room and Scanning sections.
b.
The File Room and Scanning staff members must possess knowledge of federal
privacy laws.
c.
File Room and Scanning staff members must have a knowledge of information
technology equipment used in the File Room or Scanning sections to efficiently import
documents and assemble the selected documents for scanning.
d.
File Room and Scanning staff members must possess the ability to navigate
efficiently and effectively through the paper and electronic health record, VistA Record
Tracking software, and VistA Imaging software to accurately index scanned information.
e.
File Room and Scanning staff members must possess knowledge of the health
record tracking system and the facility’s storage system to determine if paper records
exist, the location of the paper records, and the process to request or recall the records
if not at the facility, such as those at a federal storage facility.
8. FILE ROOM RECORD PROCESSES
All health records in any medium are processed in accordance with the requirements
outlined in VHA Handbook 1907.01, Health Information Management and Health
Records, or subsequent policy issue.
a.
Each health record request is prioritized to determine urgency utilizing a facility
established priority system.
b.
Upon receipt of a health record request, a File Room staff member reviews the
request and determines the location of the health record utilizing the VistA Records
Tracking System and/or Locator Cards.
(1)
If the facility has paper records, the File Room staff member must retrieve the
paper health record. The File Room staff member will charge out the correct paper
volume(s) in the VistA Records Tracking System to assure proper recording of the
location of record.
(2)
File Room staff members must ensure that the health record is secure during the
delivery to the requestor.
c.
If required, archived health records are requested from storage facilities. Record
retrieval for those records stored at the VA Record Center and Vault may be requested
online utilizing the Electronic Records Retrieval System. If stored at any other storage
facility, those records will be requested for return from the storage facility, using the
process identified between facility and other storage facility. Storage and reference
services are available to any VA on a fee-for-service-basis. Additional information can
be found at http://www.rcv.va.gov/.
May 12, 2016 VHA HANDBOOK 1907.07
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d.
If there are requests for records where the subject of the request is not registered
or found in the Master Veteran Index and no information is available, the request must
be referred to the supervisor or designee.
9. SHADOW RECORDS
Shadow records are defined as duplicate health records that are kept for the
convenience of a department or health care provider. The elimination of shadow records
should be considered based on utilization of the electronic health record by the facility.
Shadow records must not contain original documentation of the patient’s care. Original
documentation must be kept in the official health record.
10. CLOSING THE FILE ROOM
Many VA medical facilities have closed their File Rooms or are in the process of
converting their File Rooms from paper to all electronic. With this process, there are
steps to be taken to assure an organized conversion to ensure availability of health
records. The following steps should be taken to close the File Room:
a.
Set a “Closing Date”.
b.
Stage the process in the following order:
(1) Conduct research for the project.
(2) Decide on and announce the closure date to management and clinical staff
members.
(3) Organize a team.
(4) Review documentation needs.
(5) Determine appropriate paper records storage, i.e. Federal Records Center or
Records Storage Vendor.
(6) Review IT needs.
(7) Determine processes for entry of necessary information into VistA Records
Tracking System or other approved electronic system.
(8) Hold weekly meeting and provide communications on File Room closure status.
c.
Establish a team with representatives from HIM, Health Informatics, Nursing,
Clinical Staff, Information Technology, and VistA Imaging.
d.
Review template needs by identifying where paper records are being generated.
Plan for education and dates for implementation of new templates.
e.
Review HIM personnel needs.
VHA HANDBOOK 1907.07 May 12, 2016
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f.
Consider record retirement needs, including retirement of inactive records prior to
closing.
g.
Obtain location or vendor for storage of active paper records.
h.
Pull and box active records for shipment.
i.
Write a plan including processes for retrieval of records when needed, including
recall of records or scanning.
NOTE: Closure of the File Room does not eliminate the facility’s responsibility to
provide paper records when required to treat the Veteran or for other agency purposes,
such as processing Freedom of Information Act requests.
11. PERMANENT TRANSFER OF PAPER RECORDS
Paper records are no longer transferred from one VA facility to another VA facility
unless a health care provider requests the transfer.
12. EXTERNAL SOURCE DOCUMENTS
a.
External Non-VA health records (exception: Non-VA Purchased Care records)
will be reviewed by a practitioner to determine what documents are to be retained based
on the impact to present and/or continuing care. The appropriate VA medical facility
may require the practitioner complete and sign the nationally developed form approved
for local use, “Request to Scan Non-VA Documents”, available at
http://vaww.vhahim.va.gov/index.php?option=com_edocman&view=document&id=930&
catid=162&Itemid=713 (NOTE: This is an internal VA Web site that is not available to
the public), and attach the documents they wished scanned. Alternatively, a summary
progress note written by a practitioner after a review of the Non-VA source documents
may be used in lieu of filing and/or scanning any Non-VA source documents. In regards
to Non-VA Purchased Care, if signed documents cannot be obtained, the guidance
pertaining to a summary progress note should be followed in lieu of scanning the
unsigned documentation. A facility may develop a local policy that specifies which
documents may be scanned into VistA Imaging without practitioner review.
b.
If utilized by the VA facility, the Request to Scan Non-VA Documents form must
be scanned as the first sheet (coversheet) of the scanned file of the Non-VA
documents. It must include an index, so the when image opens, a list of what is
contained as part of the electronic file is viewable.
c.
Scanned source documents may be destroyed if the source document is indexed
and imaged as an exact replica of the original document, quality control processes are
in place, and there is assurance that the imaged document is stored, accessible, and
retained according to VA and NARA records retention requirements.
d.
The documents must be scanned with a minimum resolution of 300 x 300 dots
per inch (dpi).
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13. LOCATOR CARDS
Locator Card system may be maintained electronically in a secure drive. They
should be reviewed to assist in determining the disposition of the inactive or
perpetualized health records, to help identify the location that records have been
transferred to other VA facilities. Locator Cards must not be destroyed unless an exact
electronic replica is included in the facility Master Veteran Index. Locator Cards are
maintained for all patients registered or treated since the facility’s inception. These
cards include the following information: patient’s full name and any other names they
may have used; date of birth; Address; Social Security Number; dates of admission and
discharge or date of visit or encounter; disposition of patient’s records.
14. ADVANCE DIRECTIVES
a.
VHA handbook 1004.02, Advanced Care Planning and Management of Advance
Directives, establishes requirements and procedures for documenting, managing, and
rescinding advance directives. An Advance Directive is a written statement by a person
who has decision-making capacity regarding preferences about future health care
decisions in the event that the individual becomes unable to make those decisions.
b.
Where there is no electronic health record, a copy of the advance directive must
be filed in the paper health record either behind a tab specifically designated “Advance
Directive” or, at a minimum, as the first document in the current or open health record.
Each facility must develop a mechanism to ensure that the Advance Directive is
maintained in both the paper outpatient record and the paper inpatient record to
accommodate patient movement from one setting to another or from one VA facility to
another.
c.
An advance directive progress note will be created to be displayed in Postings to
CPRS.
d.
Advance directive documentation must be linked to the Advance Directive note.
e.
When an advance directive is rescinded, the note title in Text Integration Utility
(TIU) must be changed from “Advance Directive” to “Rescinded Advance Directive.”
After the TIU process is complete, all images associated with the rescinded advance
directive will be watermarked “Rescinded” and a confirmation email will be sent to the
subscribers of G.MAG SERVER mail group with the status of the watermarking.
f.
The image associated with the advance directive will be watermarked
“Rescinded” and made available to VistA Imaging Clinical Display users.
g.
The TIU note title and the associated images must be correct. If the TIU note
title is not correct and associated images are watermarked, a new advance directive
must be entered for the patient.
h.
When a note title is electronically modified to rescind an advance directive, the
title is changed from the previous title to the new title; a change history of the title name
VHA HANDBOOK 1907.07 May 12, 2016
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is not maintained. Local facility policy must state who has the authority to change a
patient note title and under what circumstances these options are utilized. The change
title option must be used.
15. DOCUMENT SCANNING PROCEDURES
a.
After meeting required competencies, the facility may determine that Scanning
staff may be authorized to create administrative progress notes for scanning purposes.
b.
Images must be linked to the correct progress note for a specific visit date.
Progress notes will be created using appropriate verbiage and/or templates as
approved by the Health Record Committee, or equivalent, that is specific to the scanned
document. If a progress note has been created to link an image, the note must be
electronically authenticated by the individual who will be creating and scanning the
document.
c.
Each facility must develop a mechanism to ensure documents are not discarded
without being scanned first, for example, by date stamping the document after scanning
to indicate that the document(s) has been scanned. Only the first page of a multi-page
document set regarding one patient is stamped.
d.
Staff members responsible for document scanning will ensure, prior to scanning,
that VHA-originated scanned images of paper documents include the patient identifiers
(full name, last four digits of the SSN, and date of birth (DOB)). Digital image capture
should meet the same criteria of patient identifier as scanned documents. However,
some paper and digital images received from sources outside VHA, such as private
hospitals or physician offices, do not contain all of the identifying data required of VHA-
originated documents. In the case of electronically received Non-VA images, the cover
page must include, at a minimum, the patient’s name and last four digits of their social
security number before importing into VistA Imaging. Each subsequent page should
contain enough identifying traits to clearly identify the patient. In the case of a large
quantity of non-VA paper documents received (as determined by local policy) the full
name, last four digits of the SSN, and DOB can be written on the first and last page of
the documents in lieu of adding the last 4 and DOB to the patient name on every page
when scanning as a complete packet.
e.
When scanning duplex documents, blank pages may only be scanned after an
“intentionally blank” or “Blank” stamp has been embossed on the document.
(1) Scanners can be set up to not scan blank pages in the scanner software. The
VistA Imaging Coordinator at the facility will determine if this is possible from the
scanner manual.
(2) If documents such as Same Day surgery packets, with one-sided and two-sided
documents, are to be scanned as a packet, then the blank pages are stamped “BLANK”
and scanned as a duplex. Use of one-sided documents is encouraged. It speeds up
May 12, 2016 VHA HANDBOOK 1907.07
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the scanning process and the ability to see documentation timely, and it negates the
possibility of accidently scanning only one side of a two-sided document.
f.
Data integrity and accurate indexing for documents must be captured using VistA
Imaging Capture in a consistent manner, and the integrity of the document must be
maintained as in the paper health record.
g.
Documents scanned into VistA Imaging Capture must utilize consistent index
terms to allow for proper sorting and searching of scanned documents by clinicians and
administrative staff.
h.
Administrative documents/images must be captured by attaching the scanned
image to the patient instead of a progress note and indexed with appropriate
administrative indices. Administrative documents/images will be captured by using the
Administrative Association in VistA Imaging Capture.
16. GUIDELINES ON IMAGE DELETION
a.
Errors involving scanned documents must be reported to the Chief, HIM, Privacy
Act Officer, or designee. The Chief, HIM, or designee will review the record and reported
error and take appropriate action.
b.
Errors by scanning staff members must be tracked for quality assurance
purposes to ensure the quality of scanning by the staff.
c.
The VA facility must have a process to assure that image deletion requests are
documented, including the specific image and/or progress note to be deleted. If the
image has annotations, follow the process outlined in the Annotation Guidance Fact
Sheet.
d.
Staff members correcting the error must print the image prior to deleting it from
the present location.
17. DESTRUCTION
a.
Source documents may be destroyed only if the source document is indexed and
imaged as an exact replica of the original document, quality control processes are in
place, and there is assurance that the imaged document is stored, accessible and
retained according to VA and NARA records retention requirements.
b.
Source documents are original documents with wet or electronic signatures, such
as consent forms or patient advance directives and copies of authenticated documents,
such as Non-VA treatment records.
VHA HANDBOOK 1907.07 May 12, 2016
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18. SCANNING AND FILE ROOM CONTINGENCY PLANS DURING COMPUTER
DOWNTIME
Preparations must be made in advance of scheduled computer downtime for
scanning of health records from the inpatient wards. Scanning timeframes will be based
upon the time document is received in the File Room. Contingency plans must specify
procedures for short- and long-term downtimes. File Room contingency plans are
prepared for management of paper-based records during computer downtimes.
Advance plans should anticipate the need to keep a manual log of records taken
outside of the File Room; how requests may be taken when the computers are
unavailable, i.e., by telephone, in person; and records delivery to support patient care.
Paper records provided in response to requests during downtime should be loaded into
the Record Tracking System when the downtime is concluded.
19. DOCUMENT SCANNING TRAINING
a.
Document Scanning training is conducted for at least 1 week prior to allowing the
employee to scan documents without direct supervision.
b.
Once the employee has reviewed the facility scanning policy, the supervisor,
Chief, HIM, and/or designee, will train the employee on the computer functions of CPRS
and VistA Imaging Capture & Display.
c.
The supervisor, Chief, HIM, and/or designee, will then go thru the processes of
scanning a document with the employee and then allow the employee to scan
documents with direct supervision.
d.
When the designated training time is completed, the employee should be given
the opportunity to scan documents without direct supervision. The Chief, HIM, and/or
designee, will then monitor and review every document scanned by the employee until
the employee has scanned a minimum of 100 consecutive documents error free for both
administrative and clinical documentation.
20. CONDUCTING QUALITY ASSURANCE MONITORS
a.
VHA Handbook 1907.01, Health Information Management and Health Records,
addresses scanning quality control processes for readability and indexing. During the
scanning process, the person scanning must verify that the document is being scanned
appropriately.
b.
Documents are to be scanned and reviewed for quality by the person scanning.
During the first quality check, the image will be checked for the overall quality and
visibility of the document. The person scanning will be responsible for reviewing each
image, to make sure that the demographic information is correct on every page, the
image is positioned as correctly as possible, and that all pages of documents have been
captured in VistA Imaging, which may include blank pages when applicable. The
second quality check of the scanned document must be verified by logging into VistA
Imaging Display. The responsible person scanning the document will perform both
May 12, 2016 VHA HANDBOOK 1907.07
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processes. These checks will be performed by the person responsible for scanning the
document and will be performed on 100 percent of the documents scanned.
c.
Areas reviewed for accuracy should include the following:
(1) Scanned to correct patient;
(2) Correct title/X-ray exam/Admin indexing used;
(3) Linked to correct consult when appropriate;
(4) Correct additional signers identified when appropriate;
(5) Required identifying information on all pages scanned;
(6) Progress Note entered correctly (containing required information);
(7) Indexed per procedure;
(8) Image legible; and
(9) Image oriented in CPRS.
d.
For quality monitoring purposes, the following should be noted:
(1) The date the document was scanned, the department it was scanned in, and the
staff that scanned;
(2) The document can be retrieved through the client display portion of VistA
Imaging; and
(3) The abstract of the scanned image/document is pulled up, right click on it, and
select the option “Image Information.”
e.
A Quality Assurance Monitor must be performed to assess the quality of
documents scanned. In order to determine which patients are selected for the monitor,
the Chief, HIM, and/or designee, picks a random sample of scanned documents. Errors
and image deletions must always be included in the Quality Image Assurance Monitors.
The facility should have a method to track image deletion requests as well as the
number of images deleted.
f.
Pertinent results of monitors must be discussed with the individual who
performed the scanning. When consistent problems are identified on any of the
reviews, 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.
g.
The Scanning Supervisor or designee must conduct quality checks for all
scanning staff quarterly at a minimum and as determined by the facility. The QA
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Review functionality in VistA Imaging Display will be utilized to identify cases to be
reviewed for each scanning staff member.
21. GUIDELINES FOR REPORTING QUALITY ASSURANCE MONITOR RESULTS
Results of quality assurance monitors may be reported to a facility oversight
committee. Action plans for any monitors not meeting established thresholds must be
prepared and completed with ongoing monitoring to assure compliance with thresholds.
22. DOCUMENT SCANNING STAFFING
HIM Scanning personnel needs must be assessed by determining the amount of
paper (documents) to be scanned and/or by transitioning File Room FTEEs to Scanning
FTEEs. A recommended measure for computing FTEE is the average amount of paper
documents scanned per hour per FTEE.
23. DOCUMENT SCANNING JOB SERIES AND PERFORMANCE DESCRIPTION
(PD)
a. The positions of staff working in the File Room are classified to the Mail and File
Series, GS-305. The appropriate appointment for positions in this series is when file
duties are predominantly File Clerk and includes Document Scanning. These positions
have been classified in this series to be at the GS- 4 level for the highest level. See the
following: GS 305-4. OPM File Clerk Decision Memorandum.
b. Although this occupation has traditionally consisted of the manually performed
operations associated with the maintenance of paper files, the GS-305 series standard
recognizes the advent of automated filing systems and the associated changes that
have occurred in the methods applied to storing records. The standard notes that these
changes have not affected the basic nature of the work, i.e., the use of an automated
system involves a rearrangement of, but no change in, basic filing processes.
Therefore, filing work performed within an automated system is encompassed by the
GS-305 series.
24. DOCUMENT SCANNING PRODUCTIVITY
HIM Health Information Management (HIM) Managers and Scanning Supervisors
utilize the tools available through VistA Imaging to monitor productivity. Processes
included in scanning/document imaging are: prepping, scanning, indexing and
analyzing. The minimum expected scanning productivity standards for fully trained
professional scanning staff members performing the scanner scope of work
requirements are specified as follows:
a. Scope of Work–Minimum Standard Per Day Note. The minimum standards
are based on a 7.5 hour workday and do not include leave, educational hours, or non-
scanning activities performed by the scanning technician. Appropriate lower standards
may be set for technicians in developmental positions. An individual scan is to
scan/import appropriate documents into VistA Imaging.
May 12, 2016 VHA HANDBOOK 1907.07
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b. Scanning All 3 Types Below. 13 Individual scans per hour or > 59 Individual
scans a day (69 pages per hour).
c. VA Administrative. 24 Individual scans per hour or > 108 Individual scans a
day (106 pages per hour).
d. VA Clinical. 16 Individual scans per hour or > 72 Individual scans a day (80
pages per hour).
e. Non-VA (Not FEE). 11 Individual scans per hour or > 50 Individual scans a day
(79 pages per hour).
NOTES: Productivity standards were developed based on input from Field Subject
matter experts as well as an analysis of the national HIM survey results of 100 percent
of all VA health care facilities on scanner productivity. Higher standards may be set as
determined to be appropriate by the HIM Manager or Scanning Supervisor based on
facility specific variables.
The Non-VA (Not Fee) standard is set at a lower than the VA standards as these
documents are less familiar to the scanning staff and may require additional time to
identify rather than familiar documents from the local facility.
Facility productivity and accuracy standards must be negotiated with your local union
representatives.
25. REFERENCES
a.
NIST Special Publication 800-53, Recommended Security Controls for Federal
Information Systems.
b.
NIST 800-66, An Introductory Resource Guide for Implementing the Health
Insurance Portability and Accountability Act (HIPAA) Security Rule.
c.
NIST 800-88, Guidelines for Media Sanitization.
d.
Title 5 U.S.C. 552a, The Privacy Act of 1974.
e.
Title 44 U.S.C.33, Disposal of Records.
f.
Title 5 CFR 2635, Standards of Ethical Conduct for Employees of the Executive
Branch.
g.
Title 21 CFR 1306, Prescriptions.
h.
Public Law 104-191, Health Insurance Portability and Accountability Act of 1996.
i.
VA Directive and Handbook 5021, Employee/Management Relations.
j.
VA Directive 6609, Mailing of Sensitive Personal Information.
VHA HANDBOOK 1907.07 May 12, 2016
14
k.
Assistant Secretary for Information and Technology Memo, May 4, 2004, “Limits
on the Use of Certain E-mail Features and Configurations.”
l.
RCS 10-1, Records Control Schedule.
m.
VHA Handbook 1004.02, Advance Care Planning and Management of Advance
Directives.
n.
VHA Handbook 1004.04, State-Authorized Portable Orders.
o.
VHA Handbook 1004.05, iMedConsent™.
p.
VHA Handbook 1605.1, Privacy and Release of Information.
q.
VHA Handbook 1907.01, Health Information Management and Health Records.
May 12, 2016 VHA HANDBOOK 1907.07
A-1
APPENDIX A
OCCUPATIONAL HEALTH RECORD-KEEPING SYSTEM (OHRS)
a.
The Employee Medical File (EMF), which is under the responsibility of
Occupation Health , is covered under multiple Federal regulations, including: Privacy
Act (PA); Health Insurance Portability and Accountability Act (HIPAA); Genetic
Information Nondiscrimination Act (GINA); Americans with Disability Act (ADAA); Family
Medical Leave Act (FMLA); Occupational Safety Health Administration; National
Personnel Records Center (NPRC); Office of Personnel Management (OPM) GOVT10
and 08VA05. OHRS is an electronic record that separates employee health information
from Veteran health information. CPRS does not meet the regulatory requirements of
the above regulations.
b.
When an employee leaves Federal service, his or her former agency must put
any long-term occupational health records in the EMF for storage at the NPRC. If there
is information in CPRS, it must be printed out and put into the EMF. Doing this when
the employee separates, which could be decades after health information is entered into
CPRS would make it impossible to determine what must be printed out because one will
not be able to determine what an occupational health record is related to employment at
the VA. Responsibility for printing those documents lies with Occupational Health with
the knowledge to determine what a long-term medical encounter is considered. This
would include physicians, nurse practitioners, physician assistants, and registered
nurses.
c.
There is no other option for order entry at this point in time, so orders must be
placed in CPRS and results are recorded there. These cannot be separated from
Veteran records and do not meet the above laws.
d.
It is highly recommended because of the requirement above that staff members
print out any clinical notes, tests, medications etc. and place them in the EMF.
