============================================================================= Run Date: OCT 20, 2004 Designation: USR*1*26 Package : USR - AUTHORIZATION/SUBSCRIPTION Priority: Mandatory Version : 1 SEQ #25 Status: Released Compliance Date: NOV 20, 2004 ============================================================================= Subject: REVIEWING BUSINESS RULES BEFORE EDITING SIGNED DOCUMENTS Category: - Informational Description: ============ This informational patch addresses a number of issues relating to the editing of signed documents. It deals with concerns brought up in a recent NOIS, and issues brought up by a recent change in VHA regulations. Specific recommendations are made regarding the modification of business rules to satisfy the requirements of the new regulations. A problem was reported in NOIS call TUA-0104-31822 where a cosigner edited a signed progress note, and the note got corrupted. The practice of editing a document that was signed by the author might have a patient safety implication and should not be allowed. This patch is a reminder to medical centers to review if Authorization Subscription Utility (ASU) business rules are in compliance with disallowing the editing of a document that was signed by the author or awaiting co-signature. Once a document is completed, it should not be edited; additional documentation should be added to the original document by addenda. Sites need to remove business rules that allow expected cosigners to edit signed and uncosigned documents. TIU does not have a category "signed," however, the following categories are considered signed: Un-cosigned, completed, amended, and retracted. According to the VHA Handbook 1907.1, no one may edit any document in these categories. Note: ===== This patch only addresses the cosigner issue of NOIS TUA-0104-31822. The issue of lost and truncated text when authors edit their own unsigned notes that was reported in this same NOIS is being addressed with the release of CPRS GUI V24 and the pending release of CPRS GUI V25 and an RPC Broker patch (XWB*1.1*35) that will be released in the near future. These rules are quoted from VHA HANDBOOK 1907.1. http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=434 Please review these business rules for compliance. Rules on signature: ================== VHA Handbook 1907.1 - Health Information Management and Health Records 1907.1, 7f - Electronic Signature Currently, there are three types of signatures in the electronic health record: (1) A "signer" is the author of the document. Once a document is signed, it cannot be edited; additional documentation can be added to the original document by addenda. (2) A "co-signer" is the attending, staff, or supervising clinician. A co-signer may also be a service chief or designee as defined by the organization's Bylaws and/or policies. A co-signer may edit and authenticate a document if the author has not already signed the document. (3) "Identified signer" and "additional signer" are synonymous and are a communication tool used to alert a clinician about information pertaining to the patient. This functionality is designed to allow clinicians to call attention to specific documents and for the recipient to acknowledge receipt of the information. Being identified as an additional signer does not constitute a co-signature. This nomenclature in no way implies responsibility for the content of or concurrence with the note. NOTE: "Identified signer" is nomenclature used by CPRS, VistA, and TIU; "additional signer" is nomenclature used by GUI. Rules on Addendum: ================= VHA Handbook 1907.1 - Health Information Management and Health Records 1907.1, 7g - Health Record Alterations and Modifications An addendum to a patient note or summary is made when a clinician deems it important to clarify information recorded in the original document or to add to the original document. The addendum option can be utilized by practitioners to continue ongoing treatment discussions, or by supervising practitioners to validate the plan of care. a. Addenda are linked to originally created documents; b. Addenda must be authenticated in an approved manner; and c. Addenda may be entered by someone other than the author. The original author and/or co-signer may be alerted to this action if appropriate TIU functionality is activated, specifically the "SEND ALERTS ON ADDENDA" parameter within the TIU DOCUMENT PARAMETERS file (8925.95). For note titles where addenda are routinely added, such as discharge plans, resident physician notes with supervision comments, or initial assessment notes, this parameter would typically be turned off. Notes on rule compliance: ======================== TIU does not have a category "signed," however, the following categories are considered signed: Un-cosigned, completed, amended, and retracted. According to the VHA Handbook 1907.1, no one may edit any document in these categories. Our analysis indicates that the following exported business rules need to be deleted: List Business Rules by DOCUMENT DEFINITION 64 Rules for CLASS CLINICAL DOCUMENTS ------------------------------------------------------------------------- 13 An UNCOSIGNED (CLASS) CLINICAL DOCUMENT may be EDITED by An EXPECTED COSIGNER 24 An UNCOSIGNED (CLASS) CLINICAL DOCUMENT may be EDITED by A CLINICAL SERVICE CHIEF List Business Rules by DOCUMENT DEFINITION 23 Rules for CLASS PROGRESS NOTES ------------------------------------------------------------------------- 9 An UNCOSIGNED (CLASS) PROGRESS NOTE may be EDITED by An EXPECTED COSIGNER List Business Rules by DOCUMENT DEFINITION 17 Rules for CLASS DISCHARGE SUMMARY -------------------------------------------------------------------------- 5 An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may be EDITED by A PROVIDER who is also An EXPECTED COSIGNER 16 An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may be EDITED by A CLINICAL SERVICE CHIEF Instructions on deleting a business rule: ======================================= The option to use is USR BUSINESS RULE MANAGEMENT under the USR CLASS MANAGEMENT menu. Select the class under which the rule is filed. (For example: CLINICAL DOCUMENTS, PROGRESS NOTE, DISCHARGE SUMMARY, etc.) Then use the Delete action to delete the offending rules. Select OPTION NAME: USR CLASS MANAGEMENT MENU User Class Management menu --- User Class Management Menu --- 1 User Class Definition 2 List Membership by User 3 List Membership by Class 5 Manage Business Rules Select User Class Management Option: 5 Manage Business Rules Select SEARCH CATEGORY: DOCUMENT DEFINITION// DOCUMENT DEFINITION Select DOCUMENT DEFINITION: DISCHARGE SUMMARY 1 DISCHARGE SUMMARY TITLE 2 DISCHARGE SUMMARY CLASS 3 DISCHARGE SUMMARY DISCHARGE SUMMARIES DOCUMENT CLASS CHOOSE 1-3: 2 DISCHARGE SUMMARY CLASS ASU Rule Browser Aug 06, 2004@08:15:04 Page: 2 of 3 List Business Rules by DOCUMENT DEFINITION 21 Rules for CLASS DISCHARGE SUMMARY + 8 An UNVERIFIED (CLASS) DISCHARGE SUMMARY may BE EDITED by a MEDICAL INFORMATION SECTION 9 An UNVERIFIED (CLASS) DISCHARGE SUMMARY may BE PRINTED by a MEDICAL INFORMATION SECTION 10 An UNSIGNED (CLASS) DISCHARGE SUMMARY may BE VIEWED by a USER 11 An UNSIGNED (CLASS) DISCHARGE SUMMARY may BE PRINTED by a USER 12 An UNSIGNED (CLASS) DISCHARGE SUMMARY may BE ADDENDED by a USER 13 An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may BE ADDENDED by a USER 14 An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may BE VIEWED by a USER 15 An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may BE COSIGNED by a CLINICAL SERVICE CHIEF 16 An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may BE EDITED by a CLINICAL SERVICE CHIEF 17 An UNSIGNED (CLASS) DISCHARGE SUMMARY may BE SIGNED by an EXPECTED SIGNER + + Next Screen - Prev Screen ?? More Actions Find Edit Rule Change View Add Rule Delete Rule Quit Select Action: Next Screen// D Delete Rule Select Business Rule(s): (8-17): 16 Deleting #16 Removing the rule: An UNCOSIGNED (CLASS) DISCHARGE SUMMARY may BE EDITED by a CLINICAL SERVICE CHIEF Are you SURE? NO// YES Deleting Business Rule. PATIENT SAFETY ISSUES RESOLVED IN THIS PATCH: ============================================ PSI-04-005 Suspected Patient Safety Incident 1/27/04 Routine Information: ==================== ============================================================================= User Information: Entered By : TRAN,TRINITY Date Entered : JUN 17, 2004 Completed By: ELGIN,GARY Date Completed: OCT 06, 2004 Released By : GIVENS,DALE S Date Released : OCT 20, 2004 ============================================================================= Packman Mail Message: ===================== No routines included