Health Information Management. 2008 PEBLO/PAD Conference. Susan M. Pierce, RHIA, CHPS, CMT Director, Health Information Management Bureau of Medicine and Surgery 2300 E Street NW Washington, DC 20372-5300 (202) 762-3162. Issues. Disposition of Medical Records Errors In Retiring Records
2008 PEBLO/PAD Conference
Susan M. Pierce, RHIA, CHPS, CMT
Director, Health Information Management
Bureau of Medicine and Surgery
2300 E Street NW
Washington, DC 20372-5300
- Analyze the record to ensure completeness
National Personnel Records Annex
1411 Boulder Drive
Rock City Industrial Center
Valmeyer, IL 62295
- check CHCS
- check DEERS
- request duty stations of AD members
from Navy Locator/Navy Personnel
Note: Do not mail old documents to the VA without confirming that they indeed have records for the same individuals.
The Services agreed to adopt the following policies to prevent back log and assure timely transmittal of records:
1. MTF staff will no longer forward HTRs or components thereof directly to
DVA. Instead, MTF staff will forward the HTRs or components thereof to
the appropriate Military Service personnel enter when
those records are complete, or not later than 30 business days after
separation/retirement, whichever comes first. Military Service personnel
out-processing centers will forward the HTR to the DVA RMC within five
business days of receiving it from the MTF.
2. As the last few weeks of service are often characterized by medical testing
and follow-up care, the practice of pre-positioning HTRs at Military Service
out-processing centers will cease.
3. Military Service out-processing centers will implement procedures to ensure that records of still-serving members and their dependents will not be transmitted to the DVA, but instead will be incorporated into the HTR of the affected person.
4. DoD Instruction 6040.43 paragraph 126.96.36.199 requires each Military
Department to “establish a policy that ensures ‘no hand carrying’ of
medical records by beneficiaries.” These records are the property of the
Department and must be transmitted through channels guaranteeing
timely receipt by the appropriate federal office. (There are no
restrictions on what Service members may do with their own copies of
5. From this point forward, decedent records (absent conflicting waivers) will
be forwarded to the DVA RMC within 30 business days of the death of the
Service member. The ASD (HA) will work with the Office of the Armed
Forces Medical Examiner to develop a plan to eliminate the back-log of
7. The Services will develop metrics and data collection mechanisms to track our progress reducing the number of incomplete HTRs and loose documentation received by the VA.
HIPAA – PHIMT – Disclosures
Issue: Scanning without indexing . . .
Best practice would be:
- Scan all network and outside consult reports into the system.
- It should be noted that written documentation on the electronic printed SF 600 is strongly discouraged. If this type of documentation and/or pictures, drawings, EKGs etc. exists, they must be scanned in AHLTA so that information is available to all providers and coding personnel.
However, many scanned documents will slow down the AHLTA system response time at your facility.
- MTFs develop local policy to ensure availability of health information when a patient presents for a visit.
- MTFs will establish procedures for short term and long term periods of system downtime.
- MTFs will have to develop a policy for coding during down times.
- Guidance for users when AHLTA goes down.
- Guidance for what to do when AHLTA data is irrevocably lost.
- Scanning solutions.