The Department of Veterans Affairs’ office of inspector general (OIG) has recommended that the Veterans Health Administration (VHA) establish and implement standard operating procedures to improve scanning and indexing of non-VA medical records into the electronic health records system.
“These procedures should clearly define all [Health Information Management] and community care staff responsibilities and the procedures for accurately scanning, importing, and indexing non-VA medical records,” according to the OIG report.
VHA should ensure that HIM officials provide and delegate training, quality assurance monitoring and quality checks for community care personnel with oversight of health record management operations.
The recommendations were made after the inspector general found that community care personnel did not always accurately encode non-VA records into the EHR system and that VHA facilities lacked standard procedures with defined responsibilities for staff.
“Inaccurate indexing of medical records poses a risk to veteran care and increases the burden on VHA staff who have to locate and correct the errors, reducing their time for other tasks,” the report reads.
