OIG Report Finds Undocumented Care in EHR at VA Medical Center

The VA OIG found that a provider did not follow a consultation procedure, which resulted in undocumented patient care in the EHR.

A Department of Veterans Affairs (VA) Office of Inspector General (OIG) report alleged that a provider at the Chillicothe VA Medical Center failed to follow a consultation process, resulting in undocumented patient care in the EHR, according to reporting from Chillicothe Gazette.

The report released on May 12 outlines an urgent care provider sending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic. The patient returned eight days later with a T12 burst fracture and rib fractures.

The OIG found that the urgent care provider verbally referred the patient for pain management, not chiropractic care. However, the OIG found that the clinician did not enter a CAM consult until eight days after seeing the patient.

The Veterans Health Administration (VHA) and facility policies require that the sending provider enters a consult and the receiving provider links the visit note directly to the consult. The sending provider must also contact the receiving provider to discuss the patient’s case for a same-day consult.

Due to this delay in the consultation process, the chiropractor and clinical massage therapist failed to review the consult before seeing the patient.

Additionally, the chiropractor and massage therapist could not link documentation to the consult and had no other process to complete the documentation, resulting in the failure to document care provided within the EHR.

The patient returned to the urgent care center eight days later, where a computerized tomography scan found an acute burst fracture and acute rib fractures.

The OIG believes that the patient’s care coordination would have improved for subsequent facility visits if the urgent care provider entered the consult on the day of the visit.  

The OIG called on the Chillicothe VA Medical Center director to ensure that the organization educates urgent care providers, chiropractors, and clinical massage therapists on consult processes and procedures and the requirement of timely documentation.

Additionally, the OIG suggested the Medical Center director conduct an internal review of the CAM processes related to patient care, including receiving and reviewing consults, scheduling appointments, checking-in patients for care, and documentation.

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