Report Summary

Title: Health Information Management Medical Documentation Backlog
Report Number: 18-01214-157 Download
Issue Date: 8/21/2019
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audit
Release Type: Unrestricted

The VA Office of Inspector General (OIG) performed this audit to determine if Veterans Health Administration (VHA) medical facilities are scanning and entering medical documentation into patients’ records accurately and in a timely manner.

VHA healthcare staff rely on medical records to manage veterans’ care. Incorporating records into patients’ electronic health records is critical because it ensures complete, accurate, and readily accessible health information to guide clinicians’ decisions.

The OIG found limited VHA monitoring and oversight created backlogs that put the continuity of patient care at risk. Based on provided data, the audit team calculated that VHA medical facilities have a cumulative medical document backlog of approximately 5.15 miles of stacked paper and at least 597,000 individual electronic document files dating back to October 2016. This occurred because staff did not scan documents and enter them into the electronic medical records in a timely manner. Staff also did not always perform appropriate reviews and monitoring to assess the overall quality and legibility of scanned documents. The OIG also found staffing shortages contributed to the backlogs.

The audit team documented that officials at seven of eight medical facilities visited did not ensure compliance with mandatory quality assurance reviews to identify and correct any errors before medical documents were shredded. Officials at the eight facilities also did not meet training requirements or consistently follow training policy.

The OIG made nine recommendations for VHA to define and promptly reduce backlogs; account for scanning demand in staffing decisions; and develop monitoring roles, controls, and procedures.