By Bridget Kennedy, CSM, CSPO, Sr. Product Line Manager, DSS, Inc.
LinkedIn: Bridget Kennedy
LinkedIn: DSS, Inc.
For the Department of Veterans Affairs (VA), the challenge of timely medical record documentation has endured, even as health care systems transitioned from paper-based records to electronic ones.
However, while technology has advanced, the VA continues to face significant hurdles in ensuring documentation is completed promptly and accurately.
Incomplete or delayed documentation creates several risks. Most notably, it can lead to compliance violations, as the VA must meet Joint Commission accreditation standards that require timely completion of critical documents such as operation notes and discharge summaries. Missing deadlines or accumulating delinquent records can threaten compliance, which is a serious consequence for any health care institution.
Beyond compliance, gaps in documentation can also disrupt revenue cycles, making it difficult to manage billing and reimbursement. Inadequate or incomplete records not only create legal risks but can hinder effective communication among care teams. This breakdown in communication could potentially compromise the quality of care provided to Veterans, affecting their overall experience and outcomes.
Currently, the VA depends on manual VistA reports and a range of local or VISN processes across various facilities. This approach leads to inefficiencies in managing documentation and adds unnecessary complexity. The Health Information Management Service (HIMS) shoulders the burden of manually tracking and following up with physicians to ensure that records are completed on time—a labor-intensive process that slows operations and wastes valuable time.
A Fresh Approach to Medical Record Documentation
Fortunately, there’s a fresh approach emerging to help modernize record documentation efforts at the VA.
New web-based applications have been specifically designed to tackle the VA’s documentation challenges head-on. These platforms streamline the process by providing actionable worklists that allow both clinicians and administrative staff to view and act on required tasks directly from the interface. This eliminates the need for double data entry and reduces the constant switching between multiple applications—saving valuable time and improving overall efficiency.
In addition to simplifying workflows, these applications also enhance information access by enabling users to manage encounters and unsigned or cosigned TIU notes within a single platform. Real-time updates ensure that signatures completed in the system are instantly reflected in VistA/CPRS, guaranteeing the records are both accurate and up to date.
For administrative users, these solutions offer robust tools for managing TIU notes, such as reassigning tasks, editing co-signers, making amendments, or even changing note titles. Additionally, the platform provides customized reporting capabilities that allow users to track documentation compliance and more effectively manage their processes, helping the VA move closer to a more efficient, compliant, and streamlined system.
Modernized Medical Record Documentation Outcomes
Designed to streamline clinical workflows, these solutions offer a wide array of benefits for both administrative tasks and patient care outcomes.
By consolidating documentation functions into one platform, these tools simplify the process and help speed up the completion of tasks. Users can manage encounters and unsigned or cosigned TIU notes within a single application, reducing the time spent navigating between different systems and ultimately improving efficiency.
Timely and complete documentation also plays a critical role in enhancing patient care. With accurate records in place, clinicians are empowered to make better-informed decisions, improving communication across care teams, and leading to better patient outcomes. These solutions don’t just support clinical workflows, they actively improve the quality-of-care Veterans receive.
In addition, these tools ease the administrative burden on the HIMS department by automating documentation management. This not only helps reduce provider burnout but also fosters better communication between clinicians and administrators, ensuring smoother and more efficient processes across the board.
By adopting web-based tools that streamline workflows, reduce administrative burden, and ensure timely, accurate documentation, the VA is setting a new standard for both compliance and care quality.
With these advancements, the VA is not just improving its documentation processes—it’s reinforcing its commitment to providing the best care possible for those who have served our country.