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Department of Veterans Affairs VHA DIRECTIVE 1907.01(1)
Veterans Health Administration Transmittal Sheet
Washington, DC 20420 April 5, 2021
VHA HEALTH INFORMATION MANAGEMENT AND HEALTH RECORDS
1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive
recertifies VHA Handbook 1907.01, Health Information Management and Health
Records, dated March 19, 2015, and maintains policy for a VHA-wide Health
Information Management (HIM) program.
2. SUMMARY OF MAJOR CHANGES:
Amendment dated December 11, 2023:
a. Updated responsibilities for VA medical facility Chiefs of Clinical Services in
paragraph 5.h.
b. Added responsibilities for VA Medical Staff in paragraph 5.j.
As of April 5, 2021, this VHA directive outlines the HIM programs, which provide
policies, responsibilities and requirements for HIM-related matters, such as health
record documentation, coding and clinical documentation integrity, release of
information, file room and scanning, transcription and medical speech recognition as
well as the overall management of health information and Veterans’ health records.
Major changes include:
a. Reducing the number of definitions previously in Appendix A and relocating
remaining definitions to paragraph 3.
b. Updating responsibilities in paragraph 5 to include the Deputy Under Secretary for
Health; Assistant Under Secretary for Health for Operations; Director, VHA HIM
Program Office; Veterans Integrated Services Network Director; and Department of
Veterans Affairs (VA) medical facility Chief of Staff.
c. Adding development of Action Plans to address medical documentation backlogs
to Appendix A and related responsibilities to paragraph 5.
d. Moving HIM program procedures included in VHA Handbook 1907.01, Health
Information Management and Health Records, dated March 19, 2015, to VHA HIM
program guides listed in paragraph 8.
e. Replacing requirements for VA medical facilities to create local policies with use of
local Standard Operating Procedures or guidelines.
3. RELATED ISSUES: VA Directive 6500, VA Cybersecurity Program, dated January
24, 2019; VA Handbook 6500, Risk Management Framework for VA Information
Systems – Tier 3: VA Information Security Program, dated March 10, 2015; VHA
AMENDED
December 11, 2023
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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Directive 1605.01, Privacy and Release of Information, dated July 24, 2023; VHA
Directive, 1907.05, Repair of Catastrophic Edits to Patient Identity, dated April 4, 2017;
VHA Directive 1907.08, Health Care Information Security Policy and Requirements,
dated April 30, 2019; VHA Directive 6300, Records Management, dated October 22,
2018; VHA Handbook 1907.02, My HealtheVet Identity Verification, dated December
30, 2014; and VHA Handbook 1907.07, Management of Health Records File Room and
Scanning, dated May 12, 2016.
4. RESPONSIBLE OFFICE: The Office of Health Informatics, Health Information
Governance (105HIG) is responsible for the content of the directive. Questions may be
addressed to the Director, VHA HIM Program Office, Office of Health Informatics at
VHAHIGHIMVAStaff@va.gov
.
5. RESCISSIONS: VHA Handbook 1907.01, Health Information Management and
Health Records, dated March 19, 2015, is rescinded.
6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before
the last working day of April 2026. This VHA directive will continue to serve as national
VHA policy until it is recertified or rescinded.
BY THE DIRECTION OF THE OFFICE OF
THE UNDER SECRETARY FOR HEALTH:
/s/ Steven Lieberman, MD, M.B.A.
Acting Deputy Under Secretary for Health
NO TE: All references herein to VA and VHA documents incorporate by reference
subsequent VA and VHA documents on the same or similar subject matter.
DISTRIBUTION: Emailed to the VHA Publications Distribution List on April 6, 2021.
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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CONTENTS
VHA HEALTH INFORMATION MANAGEMENT AND HEALTH RECORDS
1. PURPOSE......................................................................................................................... 1
2. BACKGROUND ................................................................................................................ 1
3. DEFINITIONS ................................................................................................................... 1
4. POLICY ............................................................................................................................. 2
5. RESPONSIBILITIES......................................................................................................... 2
6. TRAINING ......................................................................................................................... 9
7. RECORDS MANAGEMENT ............................................................................................ 9
8. REFERENCES ............................................................................................................... 10
APPENDIX A
DOCUMENT SCANNING................................................................................................. A-1
AMENDED
December 11, 2023
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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VHA HEALTH INFORMATION MANAGEMENT AND HEALTH RECORDS
1. PURPOSE
This Veterans Health Administration (VHA) directive maintains policy for a VHA-wide
Health Information Management (HIM) program which manages paper, electronic health
information and health records at Department of Veterans Affairs (VA) medical facilities.
AUTHORITY: 38 U.S.C. § 7301(b) and 44 U.S.C. § 3102(1).
2. BACKGROUND
a. The VHA HIM Program Office, in alignment with industry standards, develops
enterprise-wide oversight policies, processes and procedures for HIM program
implementation at VA medical facilities. These oversight policies, processes and
procedures aid in the implementation of an effective HIM program.
b. HIM professionals, which include Registered Health Information Administrators
(RHIAs) or Registered Health Information Technicians (RHITs) and Supervisory Medical
Record Administrators (Chiefs, HIM (CHIM)), are highly trained in the latest information
management technology applications; are vital to the daily operations management of
health information and health records; and ensure the quality, accuracy, integrity,
completeness and availability of patients’ health information at VA medical facilities.
c. Professional education and experience prepare HIM professionals, who are
preferably credentialed, to direct health information programs; develop systems that
document, manage, validate, analyze and use health information; and to advise medical
staff and management on medico-legal, compliance, research, quality assurance and
other related issues.
d. Along with administrative and clinical staff, HIM professionals play an integral role
in the development of future strategies for initiatives based on the organization’s health
information.
e. HIM professionals serve as a resource to the VA medical facility and guide
decision-making activities related to health information systems, health record content,
authentication of health record entries, correction of documentation errors,
documentation approaches, record retention and storage, data validation and analysis,
performance improvement, information governance, medico-legal or tort claim issues,
information systems backup and disaster recovery.
3. DEFINITIONS
a. D
ocument Scanning. Document scanning, or document imaging, is a process by
which a paper document is converted to an electronic file. Requirements for an effective
Document Scanning Program for the VA medical facility, including requirements for
scanning, training certification and Quality Assurance Monitoring, are included in
Appendix A of this directive.
AMENDED
December 11, 2023
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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b. Electronic Health Record. Electronic health record (EHR) is the digital collection
of patient health information resulting from clinical patient care, medical testing and
other care-related activities. Authorized VA health care providers may access EHR to
facilitate and document medical care. EHR comprises existing and forthcoming VA
software including Computerized Patient Record System (CPRS), Veterans Information
Systems and Technology Architecture (VistA) and Cerner platforms. NOTE: The
purpose of this definition is to adopt a short, general term (EHR) to use in VHA national
policy in place of software-specific terms while VA transitions platforms.
4. POLICY
It is VHA policy that VHA provide high quality health care for Veterans through
implementation of an effective HIM program which includes the following functions:
coding, clinical documentation integrity (CDI), release of information (ROI), file room
and scanning, transcription and medical speech recognition.
5. RESPONSIBILITIES
a. U
nder Secretary for Health. The Under Secretary for Health is responsible for
ensuring overall VHA compliance with this directive.
b. D
eputy Under Secretary for Health. The Deputy Under Secretary for Health is
responsible for:
(1) Supporting the program office with implementation and oversight of this directive.
(2) Ensuring that VHA-wide HIM policies and procedures are implemented through
the VHA HIM Program Office.
(3) Ensuring the VHA HIM Program Office mission and vision are accomplished by
supporting resources, funding and staffing.
c. Assistant Under Secretary for Health for Operations. The Assistant Under
Secretary for Health for Operations is responsible for:
(1) Communicating the contents of this directive to each of the Veterans Integrated
Services Networks (VISNs).
(2) Assisting VISN Directors to resolve implementation and compliance challenges in
all VA medical facilities within that VISN.
(3) Providing oversight of VISNs to ensure compliance with this directive and its
effectiveness.
d. Director, Health Information Management Program Office. The Director, HIM
Program Office, is responsible for:
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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(1) Developing short- and long-term goals for the HIM program that align with VHA’s
strategic plan.
(2) Developing and implementing the VHA HIM program.
(3) Developing, issuing, reviewing and coordinating HIM policies for VHA in
alignment with VA policy.
(4) Providing clarifying guidance for VISNs and VA medical facility-level Chiefs of
HIM (CHIMs).
(5) Providing VHA-specific HIM ad hoc training, tools and resources.
(6) Coordinating investigations and responses to HIM inquiries and related
correspondence from Veterans, Congressional representatives and others.
(7) Providing expert guidance to VHA staff regarding applicable Federal laws, VHA
policy, Joint Commission standards, the Commission on Accreditation of Rehabilitation
Facilities (CARF) and other regulatory and accrediting agencies’ policies and practices
related to HIM processes and procedures.
(8) Coordinating with the Office of Inspector General (OIG), High Reliability
Organization (HRO) and Office of Quality, Safety and Value (QSV), to include Quality
Management, Patient Safety, and Systems Redesign, on regulatory and programmatic
issues affecting EHR documentation.
(9) Collecting and reviewing HIM-related performance metrics and advising VA
medical facilities when HIM Action Plans are required.
(10) Reviewing VA medical facility Action Plans for remediation of backlogs and
other related HIM issues to determine if the Action Plan appropriately addresses the
deficiency. The HIM Program Office staff will provide guidance to the VA medical facility
to update any deficient Action Plans.
(11) Concurring with selections for HIM assignments proposed by the VISN Director,
VA medical facility Director and VA medical facility CHIM, prior to firm offer, to ensure
appropriately designated assignments and appropriately qualified candidates.
e. Veterans Integrated Services Network Director. The VISN Director is
responsible for:
(1) Ensuring that all VA medical facilities within the VISN comply with this directive
and informing leadership when barriers to compliance are identified.
(2) Ensuring compliance with, and implementation of, all internal and external HIM
requirements in accordance with Federal statutes and regulations, and VA and VHA
regulations and policies relating to HIM within their respective VA medical facilities.
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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(3) Ensuring procedures consistent with this directive are established within their
respective facilities and programs and distributed to all personnel.
(4) Ensuring that all remediation activities associated with Action Plans, as
requested by the VHA HIM Program Office, are completed in accordance with
timeframes specified on Action Plans.
(5) Ensuring all selections for managerial and supervisory 0669 Medical Records
Administrator (MRA) and 0675 Medical Record Technician (MRT) assignments receive
national VHA HIM Program Office concurrence, prior to firm offer, to ensure
appropriately designated assignments and appropriately qualified candidates. This
includes the assignment for MRA VISN HIM and Supervisory MRT assignments such as
Supervisory MRT (Coder) Consolidated Coding Unit (CCU).
f. VA Medical Facility Director. The VA medical facility Director is responsible for:
(1) Ensuring adequate resources are available to accomplish the duties and
responsibilities of the HIM program as outlined in this directive.
(2) Ensuring overall VA medical facility compliance with this directive and
appropriate corrective action is taken if non-compliance is identified.
(3) Ensuring that a qualified VA medical facility CHIM is designated in accordance
with VA Handbook 5005/130, Staffing, Appendix G33, dated May 28, 2020, and
charged with implementing an effective HIM Program throughout the VA medical facility,
including sites of care under the auspices of that VA medical facility.
(4) Ensuring the VA medical facility CHIM is involved in all decisions, both technical
and administrative, that impact, define and control access to, and storage and
disclosure of patient health records.
(5) Ensuring all selections for managerial and supervisory 0669 MRA and 0675 MRT
assignments receive national VHA HIM Program Office concurrence, prior to firm offer,
to ensure appropriately designated assignments and appropriately qualified candidates.
This includes the assignments for VA medical facility CHIM or Assistant CHIM,
Supervisory MRT Coder, ROI and Health Information Technician (HIT) assignments.
(6) Ensuring VA medical facility Standard Operating Procedures (SOPs) or
guidelines and procedures for HIM activities and functions are established and
distributed to all VA medical facility staff. NOTE: If using an SOP, VA medical facilities
must use the standardized VHA SOP template available on the HIM SharePoint at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
(7) Ensuring that documentation and personnel are available for on-site assessment
and for consultative services remotely by the VHA HIM Program Office when reviews
are conducted, or issues are identified.
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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(8) Reviewing and if appropriate, approving Action Plans for addressing HIM
backlogs and other HIM-related issues and providing resources and support for
remediation to accomplish plans.
(9) Ensuring HIM remediation activities associated with Action Plans, as requested
by the VHA HIM Program Office, are completed in an accurate and thorough manner
while meeting timelines included in Action Plans.
(10) Ensuring health record file room and scanning activities are managed by a
qualified professional who is knowledgeable and experienced in all aspects of health
record file room management and scanning activities, in accordance with VHA
Handbook 1907.07, Management of Health Records File Room and Scanning, dated
May 12, 2016.
(11) Ensuring medical coding activities are managed by a qualified professional who
is knowledgeable and experienced in all aspects of International Classification of
Disease (ICD), Current Procedural Terminology (CPT) and Healthcare Common
Procedure Coding System (HCPCS) coding conventions and guidelines, and in third-
party reimbursement requirements. NOTE: For more information, please refer to the
VHA HIM Clinical Coding Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
(12) Ensuring ROI activities are managed by a qualified professional who is
knowledgeable and experienced in all aspects of ROI, including privacy requirements
for disclosure of health records. NOTE: For more information, please refer to the VHA
HIM Release of Information Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
(13) Ensuring Records Management activities are managed by a qualified
professional who is knowledgeable and experienced in all aspects of records
management, in accordance with VHA Directive 6300, Records Management, dated
October 22, 2018.
(14) Ensuring CDI activities are managed by a qualified professional who is
knowledgeable and experienced in all aspects of the VHA CDI Program. NOTE: For
additional information on the CDI program, please refer to the VHA Clinical
Documentation Integrity Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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(15) Ensuring activities for other functions that may be under the purview of HIM
(e.g., transcription, cancer registry, medical speech recognition or various HIM-related
contracts) are managed in accordance with applicable VHA policies and procedures.
g. VA Medical Facility Chief of Staff or VA Medical Facility Associate Director
for Patient Care Services. The VA medical facility Chief of Staff (COS) or the VA
medical facility ADPCS, depending on the VA medical facility, is responsible for
ensuring VA clinical staff adhere to health record timeliness, accuracy and completion
for those staff members for which they have oversight and accountability.
h. V
A Medical Facility Chiefs of Clinical Service. VA medical facility Chiefs of
Clinical Services are responsible for the management of the clinical content of health
records for those VA medical facility health care providers under their purview
contributing to the content of the patient health record.
i. V
A Medical Facility Chief, Health Information Management. The VA medical
facility CHIM is responsible for:
(1) Performing duties, as needed, to ensure a robust, effective and compliant HIM
program including but not limited to training, monitoring and analysis.
(2) Developing short- and long-term goals for the VA medical facility HIM program,
aligned with VHA’s strategic plan and appropriate VISN and VA medical facility goals
and objectives.
(3) Ensuring that the VA medical facility HIM program is in compliance with the HIM
Health Record Documentation Program Guide processes, including but not limited to
those for health information privacy and security, access and sensitive records; health
record documentation; complete and incomplete health records; alterations and
modifications; disaster recovery; and record retention, disposition and transfer of health
records. NOTE: For more information, please refer to the VHA HIMHealth Record
Documentation Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
(4) Developing, documenting and maintaining current VA medical facility HIM SOPs
or guidelines in accordance with VHA HIM policy, program guides, fact sheets, Practice
Briefs and other applicable references and resources. NOTE: If using an SOP, VA
medical facilities must use the standardized VHA SOP template available on the HIM
SharePoint at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
(5) Release of Information. Managing the day-to-day activities of releasing the VA
medical facility’s health records in accordance and compliance with VHA Directive
1605.01, Privacy and Release of Information, dated July 24, 2023, and the VHA HIM
Release of Information Program Guide, available at:
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public. The VA medical facility
CHIM must work closely with the VA medical facility Privacy Officer to ensure
compliance with all privacy laws, regulations and policies.
(6) Health Record Management and Monitoring.
(a) Ensuring administrative management of health records, which includes planning,
managing, advising and directing the health information program in accordance with
applicable Federal laws, VA medical facility medical staff bylaws, VHA policy, Joint
Commission standards, CARF, OIG and other regulatory and accrediting agencies.
(b) Establishing criteria for health record reviews utilizing, at a minimum, current
Joint Commission standards and VHA initiatives, as appropriate, to include all areas of
patient care. Guidance for health record reviews is located in the HIM Practice Brief,
Health Record Review, available at
https://dvagov.sharepoint.com/sites/vhahealth-
information-management/SitePages/Health-Information-Management-Home-Page.aspx.
NO TE: This is an internal VA website that is not available to the public.
(c) Conducting audits and monitors to ensure accurate, relevant, timely and
complete health records, in accordance with VHA policy and Joint Commission health
information protocols.
(d) Reporting audit and monitor results to the VA medical facility’s Medical Record
Committee or equivalent committee responsible for oversight of the quality of the health
record.
(e) Developing and implementing processes and monitors to assure all file room and
scanning activities are completed in an accurate and timely manner, including reporting
to the Medical Record Committee or equivalent committee responsible for oversight of
the quality of the health record.
(f) Ensuring that all document scanning requirements listed in Appendix A of this
directive are followed, notifying the VA medical facility Director when a medical
documentation scanning backlog exists and working with any areas that are not meeting
the required timeline included in their Action Plan to address the backlog.
(g) Developing and implementing processes and monitors for other functions that
may be under the purview of HIM such as Transcription, Cancer Registry, Records
Management, Medical Speech Recognition or various HIM-related contracts, to assure
all activities are completed in an accurate and timely manner in accordance with
applicable VHA policy, program guides, Fact Sheets, Practice Briefs and other
applicable references and resources.
(h) Maintaining awareness of any use of shadow records and, with the advice of the
Facility Records Manager and the Medical Record Committee or equivalent committee
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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responsible for overseeing the health record, determining the need to continue the use
of any shadow health records and documenting such action in the committee minutes.
(i) Ensuring erroneous patient health information in VA medical facility health records
is corrected electronically or on paper in accordance with the HIM Erroneous Document
Corrections Guidebook and the VHA Health Record Documentation Program Guide,
available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public. Only the VA medical
facility CHIM, Privacy Officer or designee (as determined locally) is authorized to make
privacy amendments as outlined in VHA Directive 1605.01. No edit, reassignment,
deletion or alteration of any documentation after the manual or electronic signature has
been completed can occur without the approval of the CHIM, Privacy Officer or
designee.
(j) Signing the administrative progress note when the appropriate medical staff
committee (e.g., Medical Records Committee) declares an incomplete health record to
be filed as complete.
(k) Approving the physical removal of original paper health records from the treating
VA medical facility. NOTE: Only the VA medical facility CHIM, or designee, can grant
this approval as custodian of the health record.
(7) Coding and Clinical Documentation.
(a) Ensuring that the functions of a clinical coding program are established,
maintained, supported, and in compliance with the VHA HIM Clinical Coding Program
Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
(b) Managing and providing oversight for all ICD, CPT and HCPCS coding to ensure
coded data accurately reflects the diagnoses and services provided to patients.
(c) Ensuring that the functions of a CDI program are established, maintained,
supported and in compliance with the VHA CDI Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
(8) Guidance and Staffing.
(a) Providing expert guidance to the VA medical facility staff on all HIM-related
matters including but not limited to health record documentation, coding, CDI, ROI, file
room and scanning, transcription and medical speech recognition.
(b) Utilizing references and resources available on the VA intranet, making
independent decisions and issuing guidance on HIM subject matter. NO TE: Guidance
April 5, 2021 VHA DIRECTIVE 1907.01(1)
9
should only be sought from VHA HIM Program Office when a local determination is not
possible.
(c) Ensuring VHA HIM Program Office requests, inquiries and correspondence are
addressed within the time frames specified.
(d) Ensuring all selections for supervisory 0669 MRA and 0675 MRT assignments
receive national VHA HIM Program Office concurrence, prior to firm offer, to ensure
appropriately designated assignments and appropriately qualified candidates. This
includes the assignments for Assistant CHIM, Supervisory MRT Coder, ROI and HIT
assignments.
(e) Participating or contributing to orientation and training of new and existing staff
that are expected to have contact with, or access to, VA medical facility health records.
j. VA Medical Facility Health Care Providers. VA medical facility health care
providers are responsible for:
(1) Completing and authenticating (i.e., signing or co-signing) health record
documentation within time frames defined by this directive, VA medical facility SOPs,
guidelines and medical staff bylaws and by the VHA HIM Health Record Documentation
Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public..
(2) Completing encounter information (primary and secondary ICD diagnosis codes,
CPT/HCPCS codes, and service connection/special authority designation) that is
associated with the service(s) provided.
NO TE: Encounter and supporting documentation should be completed during, or as
soon as practicable after care is provided in order to maintain an accurate and up-to-
date medical record. In all cases, encounter and documentation must be completed no
later than 7 calendar days from the visit date.
6. TRAINING
The following training is required for all VA staff performing document scanning and
importing in the VistA Imaging Clinical Capture software: Talent Management System
(TMS) Program, VistA Scanning Training Certification and other specified training
identified by the VHA HIM Program Office. See Appendix A, paragraph 5 for more
information regarding the scanning training certification.
7. RECORDS MANAGEMENT
All records regardless of format (e.g., paper, electronic, electronic systems) created
by this directive must be managed as required by the National Archives and Records
Administration (NARA) approved records schedules found in VHA Records Control
April 5, 2021 VHA DIRECTIVE 1907.01(1)
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Schedule 10-1. Questions regarding any aspect of records management should be
addressed to the appropriate Records Officer.
8. REFERENCES
a. 38 U.S.C. § 7301(b).
b. 44 U.S.C. § 3102(1).
c. VA Handbook 5005/130, Staffing, Appendix G33, dated May 28, 2020.
d. VHA Directive 1605.01, Privacy and Release of Information, dated July 24, 2023.
e. VHA Directive 6300, Records Management, dated October 22, 2018.
f. VHA Handbook 1907.07, Management of Health Records File Room and
Scanning, dated May 12, 2016.
g. HIM Erroneous Document Corrections Guidebook, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
h. Scanning Staffing Model (see Adaptive Scanning Staffing Model folder), available
at: https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
i. VHA HIM Health Record Documentation Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
j. VHA HIM Clinical Coding Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
k. VHA Clinical Documentation Integrity (CDI) Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
l. VHA HIM Practice Brief, Community Care – Scanning/VistA Imaging Best
Practices, available at: https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
April 5, 2021 VHA DIRECTIVE 1907.01(1)
11
m. VHA HIM Practice Brief, Health Record Review, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
n. VHA HIM Practice Brief, Remote Data Sources, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
o. VHA HIM Release of Information Program Guide, available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
April 5, 2021 VHA DIRECTIVE 1907.01(1)
A-1
APPENDIX A
DOCUMENT SCANNING
1. DOCUMENT SCANNING
This appendix describes additional information regarding Veterans Health
Administration (VHA) document scanning requirements.
a. Scanned, wet-signed documents may be linked in the electronic health record
(EHR) to a progress note, consult or encounter. Scanned documents may be attached
at the patient level only in the case of an administrative document.
b. Only those documents that cannot be created in or interfaced with EHR must be
scanned. EHR documents from Department of Veterans Affairs (VA) medical facilities
must not be printed and scanned as the documents can be viewed in the Joint
Longitudinal Viewer (JLV). Scanned images, digital X-rays and other digital images from
other VA medical facilities can be viewed in JLV. Development of VA medical facility
document scanning Standard Operating Procedures (SOPs) is a shared responsibility
among Health Information Management (HIM) and other appropriate service lines.
NO TE: See VHA Handbook 1907.07, Management of Health Records File Room and
Scanning, dated May 12, 2016, for additional information.
c. Prior to scanning, VHA-originated paper documents must include two patient
identifiers, for example, the patient’s full name and date of birth (DOB). If the patient
cannot be clearly identified from these two identifiers, HIM staff will return the form to
the originating office or author for another identifier such as home address. Clinical
documents received from sources outside of VHA, such as private hospitals and
physician offices, should meet the same patient identifier criteria as VHA-originated
paper documents. 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 Veterans Information Systems and Technology Architecture (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. NOTE:
For additional information on scanning and importing Community Care documents,
please refer to the HIM Practice Brief, Community Care – Scanning/VistA Imaging Best
Practices available at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public. For additional information on
scanning best practices, please refer to the HIM SharePoint site at
https://dvagov.sharepoint.com/sites/vhahealth-i
nformation-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public. It is continuously updated to
contain scanning best practices for VA EHR platforms that are available and in use. For
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additional information on remote data sources, please refer to the HIM Practice Brief,
Remote Data Sources available at:
https://dvagov.sharepoint.com/sites/vhahealth-
information-management/SitePages/Health-Information-Management-H ome-Page.aspx.
This is an internal VA website that is not available to the public.
d. Photographs also need to include the patient identifier but may not be able to
accommodate the identifier when taking a close-up photograph, such as a wound.
Therefore, when photographs cannot capture the patient identifier, take a picture with
the patient identification (name, and DOB), such as on an index card with the
information to be used as the first image in the study. Then take the close-up picture(s)
of the body part or area. Finally, take another identification picture at the end. The
identification pictures must be the first and last picture in the series with the non-
identified close-up pictures in the middle. N OTE: It may be beneficial to take wide-angle
picture(s) before the close-up pictures when possible.
e. All internal and external documents must be imported or scanned into the EHR
within 5 business days of receipt as ensured by the VA medical facility Chief, HIM
(CHIM) (see paragraph 5.i. in the body of the directive). Internal and external
documents must be made available to the scanning area upon receipt of the
documentation in order for the information to be imported or scanned, allowing both
clinical and administrative staff to view the image without delays. The VA medical
facility CHIMs will notify VA medical facility Directors through their established chain of
command when a medical documentation backlog exists and take appropriate actions.
If documentation has been received, but not imported or scanned into the EHR within
5 days of receipt at the VA medical facility, an Action Plan detailing how the backlog
will be decreased, including timeframe for completion, must be submitted to the VA
medical facility Director through the locally established chain of command, the
Veterans Integrated Services Networks (VISN) Point of Contact (POC), VHA HIM
Program Office and Facility Office of Community Care Manager (if applicable). The VA
medical facility CHIM must monitor all areas of the VA medical facility performing
scanning and importing functions to ensure compliance across the VA medical facility.
The VA medical facility CHIM should work with the area that is not meeting the
required timeline which is included in the overall Action Plan. If upon the agreed point
in time the backlog still exists, the Action Plan will be re-addressed and more
aggressive actions must be taken to eliminate the backlog. Once the VA medical
facility is in compliance with the 5 business days requirement, this monitoring will be
continued and reported at regular identified intervals to ensure sustainment.
f. Scanning clerks may not close or complete consults administratively if there is any
clinical decision making involved (e.g., follow-up care, more than one consult of the
same specialty available for selection). It is within the duties of a scanning clerk to close
or complete a consult including when it is considered “electronic filing.” The National
Archives and Records Administration (NARA) disposition authority for EHRs allows VA
to destroy source documents after scanning but only if health record retention and
retrieval requirements can be met and quality control processes are in place. In
accordance with the NARA disposition authority, document imaged records must be
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retained to satisfy the “75-year after the last episode of care” retention requirement.
NO TE: Please see VHA Handbook 1907.07 for Scanning Supervisor responsibilities.
g. Staff performing scanning/importing are to review each scanned document during
the scanning process for quality control purposes to ensure it is readable and
retrievable for health record retention. Original source documents are retained until a
Quality Assurance Monitor has been conducted by a third party from the VA medical
facility (i.e., supervisor, quality coordinator) on a sample of the scanned documents.
See paragraph 2 (Quality Assurance) below.
h. Original source documents may be retained after scanning if there is a
compelling business reason to do so, defined by the VA medical facility dependent upon
situational need, for example, a specialized audit.
i. VA medical facility SOPs or guidelines on scanning documents must address
quality control processes for:
(1) Image quality and alternative means of capturing the data when the quality of the
source document cannot meet image quality controls;
(2) Integrity of data capture;
(3) Accurate linking of scanned items or documents to correct a record;
(4) Accurate indexing of the document;
(5) Correction process of erroneously scanned documents;
(6) Staffing issues, such as who is authorized to create administrative progress
notes for scanning, who is given permissions to scan documents after meeting
competencies and where the scanning takes place (centralized versus decentralized
scanning);
(7) The handling of external source documents; and
(8) How a scanned document must be annotated to identify that it has been
scanned, for example, using a stamp on the scanned document. NOTE: If using an
SOP, VA medical facilities must use the standardizd VHA SOP template available on
the HIM SharePoint at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. This is an
internal VA website that is not available to the public.
2. QUALITY ASSURANCE
a. A Quality Assurance Monitor must be performed by the Scanning Supervisor or
delegated designee, such as the Community Care Supervisor, to assess the quality of
documents scanned/imported. In order to determine which patients are selected for the
monitor, the VA medical facility CHIM, or delegated designee picks a random sample of
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scanned/imported documents. The samples must regularly include documents
scanned/imported by Community Care staff. Errors and image deletions must always be
included in the Quality Image Assurance Monitors. The VA medical facility must have a
method to track image deletion requests as well as the number of images deleted.
NO TE: See related responsibilities for the VA medical facility CHIM under paragraph 5.i.
in this directive.
b. The minimum sample size for the Scanning Quality Assurance Monitor is based
on VA medical facility complexity and is required to be:
(1) Level 1 VA medical facilities: 150 scanned/imported documents.
(2) Level 2 VA medical facilities: 100 scanned/imported documents.
(3) Level 3 VA medical facilities: 50 scanned/imported documents.
c. If an error rate is found to be less than 95% accuracy, the VA medical facility will
perform an additional comprehensive review of 50 additional scanned/imported
documents and provide remedial training.
d. 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.
e. The Scanning Supervisor or delegated designee must conduct quality assurance
reviews for all scanning staff quarterly at a minimum and as determined by the VA
medical facility. The Quality Assurance (QA) Review functionality in VistA Imaging
Display will be utilized to identify cases to be reviewed for each scanning staff member.
If using the Cerner scanning product, the productivity report would be utilized for review
of scanning quality compliance.
3. REQUIREMENTS FOR REPORTING QUALITY ASSURANCE MONITOR RESULTS
Results of Quality Assurance Monitors must be reported by the Scanning Supervisor
or delegated designee to a VA medical facility Medical Record Committee or equivalent
committee responsible for the quality of the health record. Action plans for any monitors
not meeting established thresholds must be prepared and completed with ongoing
monitoring to assure compliance with thresholds.
4. STAFFING MODEL
A scanning staffing model is available to VA medical facilities to ensure appropriate
staffing levels to support future workload. The Scanning Staffing Model is available on
the HIM SharePoint (see Adaptive Scanning Staffing Model folder) at:
https://dvagov.sharepoint.com/sites/vhahealth-information-
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management/SitePages/Health-Information-Management-Home-Page.aspx
. NOTE:
This is an internal VA website that is not available to the public.
5. ANNUAL SCANNING TRAINING CERTIFICATION
VA medical facility CHIMs are required to use the Talent Management System
(TMS) Program, VistA Scanning Training Certification (Item # 43853), to certify that staff
performing scanning duties have been properly trained. The VA medical facility CHIM is
required to assign training consistent with VHA Handbook 1907.07 to all staff
performing scanning or importing prior to allowing VA medical facility staff to scan/index
documents without direct supervision including when needed for corrective actions.
Included are staff in HIM as well as other locations in the facilities, such as Community
Care, Patient Care Clinics and Community Based Outpatient Clinics (CBOCs). The VA
medical facility CHIM must utilize the scanning training contained on the Scanning
Training Checklist to document that the training has been provided to all staff
performing scanning to ensure proper training has been accomplished. CHIMS will
annually certify that all relevant staff, including new staff who scan or import, have been
trained. The training certification will be documented using the following HIM SharePoint
site:
https://dvagov.sharepoint.com/sites/vhahealth-information-
management/SitePages/Health-Information-Management-Home-Page.aspx. NOTE:
This is an internal VA website that is not available to the public.
