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Department of Veterans Affairs

RECORDS CONTROL SCHEDULE 10-1

Veterans Health Administration Washington DC 20420

TABLE OF CONTENTS PART ONE

  1. Purpose ............................................................................................................................................................. I-1

  2. Introduction ....................................................................................................................................................... I-1

  3. Records Management Responsibilities ............................................................................................................. I-2

  4. Disposition of Records...................................................................................................................................... I-2

  5. Permanent and Unscheduled Records............................................................................................................... I-2

  6. Media Neutral Records ..................................................................................................................................... I-3

  7. Damage to and Unauthorized Destruction of Records ..................................................................................... I-3

  8. Records Freezes & Litigation Holds ................................................................................................................. I-4

  9. Vital Records .................................................................................................................................................... I-5

  10. Personal Papers ............................................................................................................................................... I-5

  11. Termination of Office/Service and Deactivation of Field Activity ................................................................ I-5

  12. Department of Veterans Affairs (VA) Policy ................................................................................................. I-5

CHAPTER ONE: GENERAL ADMINISTRATION AND MANAGEMENT RECORDS

1000 Records Common to Most Offices within Agencies (GRS 23)

VHA RECORDS CONTROL SCHEDULE 10-1

  1. PURPOSE

The Records Control Schedule (RCS) 10-1 provides Veterans Health Administration (VHA) records retention and disposition requirements for VHA Central Office, Program Offices, and field facilities. The primary purpose of this revision is to incorporate changes to RCS 10-1 issued since the last publication date of March 20, 2017. The schedule is divided into eight chapters. Each chapter covers a group of records, e.g., chapter one covers administrative records. The first four chapters include most of the National Archives and Records Administration (NARA) General Records Schedules (GRS). Space for additional records schedules is available to allow for future expansion. The VHA Records Management Office intends to update this schedule every three years in order to publish the most up to date records management requirements. Between updates the VHA Records Management Office will post new or revised schedules on the HIM/RM (Health Information Management/Records Management) website. Schedules are not required to be in the RCS 10-1 to be a legal schedule. Once a schedule is approved by the Archivist of the United States it must be used to manage the agencyÕs records.

  1. INTRODUCTION

a. Title 44, Section 3301, of the United States (U.S.) Code defines records as Òall books, papers, maps, photographs, machine-readable materials or other documentary materials, regardless of the physical form or characteristics, made or received by an agency of the U.S. Government under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies decisions, procedures, operations, or other activities of the government or because of the information value of data in them. Library and museum material made or acquired and preserved solely for reference or exhibition purposes, extra copies of documents preserved only for convenience or reference, and stocks of publications and of processed documents are not included. These items are referred to as non-record materials.

b. The VHA Records Control Schedule (RCS) 10-1 is the main authority for the retention and disposition requirements of VHA records. It provides a brief description of the records and states the retention period and disposition requirements. It also provides the NARA disposition authorities or the GRS authorities, whichever is appropriate for the records, in addition to program and service sections.

c. The GRS provides disposal authorities for temporary administrative records common to all Federal agencies. It covers records relating to: personnel, budget and finance, procurement, information technology, and other common functions and activities of Federal agencies. Any deviation from the GRS must be authorized by NARA in accordance with 36 Code of Federal Regulations (CFR) 1228.42(B). Requests for deviations from either the RCS 10-1 or GRS retention and disposition requirements are to be submitted to the VHA Records Management Office via the Facility requesting the change and the primary VHA Program Office with authority over the record type that is being requested for change.

  1. RECORDS MANAGEMENT RESPONSIBILITIES

a. The Assistant Deputy Under Secretary for Informatics and Analytics (10P2), Executive Director Information Governance (10P2C) Health Information Management/Records Management Office will be referred to as the VHA Records Management Office throughout this document. The VHA Records Management Office is responsible for developing policies and procedures for effective and efficient records management throughout VHA including VHA Program Offices and Veterans Administration (VA) Medical Centers. In addition, the Office acts as the liaison between VHA and NARA on issues pertaining to records management practices and procedures.

b. VHA Field/Facility Records Managers are responsible for all records management activities at their site.

c. All VHA employees are responsible for ensuring that records are created, maintained, protected, and dispositioned in accordance with NARA regulations and VA policies and procedures.

  1. DISPOSITION OF RECORDS

The RCS 10-1 contains retention and disposition requirements for VHA records authorized by NARA or assigned a GRS authority. Record disposition refers to the transfer of records to an approved records storage facility, transfer of permanent records to NARA, the destruction of records, or other appropriate actions to dispose of records. Unless retrieved; records transferred to a storage facility shall be dispositioned after expiration of their retention requirements.

  1. PERMANENT AND UNSCHEDULED RECORDS

Permanent and unscheduled records in VHA custody must be reported through the VHA Records Management Office to NARA. Permanent (archival) records are defined as records appraised by NARA to have sufficient historical value or other value to warrant permanent preservation at the NARA. Un-appraised and unscheduled records are records that have not been evaluated to determine their record retention or disposition. Such records are to be retained until they receive disposition authority from NARA. The VHA Program Offices responsible for unscheduled records shall work with the Field/Facility Records Manager, VHA Records Management Office and the VHA Records Officer to identify, describe and submit to NARA a request for disposition authority using the NARA electronic Records Archives (ERA) system.

  1. MEDIA NEUTRAL RECORDS

a. A media neutral schedule item on a records disposition schedule (i.e., SF 115, Request for Records Disposition Authority or NARA Electronic Records Archives (ERA) records scheduling module) applies to the described records regardless of their medium. Program offices must submit a new schedule request through the VHA Records Management Office to NARA for approval of electronic versions of previously scheduled records if:

(1) The content and function of the records have changed significantly (e.g., the electronic records contain information that is substantially different from the information included in the hard copy series or are used for different purposes).

(2) The previously approved schedule explicitly excluded electronic records. (3) The electronic records consist of program records maintained on an agency Web site. (4) The electronic records consist of temporary program records maintained in a format other than scanned image AND the previously approved schedule is not media neutral.

b. Temporary still pictures, sound recordings, motion picture film, and video recordings. Apply the previously approved schedule to digital versions.

c. Scanned images of temporary records, including temporary program records. Apply the previously approved schedule.

d. Other temporary records maintained in an electronic format other than scanned images:

(1) For temporary records that are covered by an item in the GRS (other than those GRS items that exclude electronic master files and databases) or an agency-specific schedule that pertains to administrative housekeeping activities, apply the previously approved schedule. If the electronic records consist of information drawn from multiple hard copy series, apply the previously approved schedule item with the longest retention period. This is common when creating an electronic system that replaces a number of paper and electronic record types. The older systems and paper records are now placed into a new system. In the past these records may have covered various disposition life cycles. In the case of finance records the range could have been from one to six years. If the records in the new electronic system cannot be dispositioned separately then they must be kept for the longest disposition, in this case six years.

(2) For temporary program records covered by a NARA-approved media neutral schedule item (i.e., the item appears on a schedule submitted to NARA for approval before December 17, 2007, that is explicitly stated to be media neutral, or it appears on a schedule submitted to NARA for approval on or after December 17, 2007, that is not explicitly limited to a specific recordkeeping medium), are considered media neutral. An example of this is the Health Records Folder File or Consolidated Health Record (CHR). The original NARA approved records disposition schedule was NARA (Job No. N1-15-91-6 item 1). This schedule was written and approved in 1991 and was for the paper health record only. In 2000 (VHA) created an ÒElectronic Health RecordÓ. Since this record was not paper VHA was required to submit to NARA a request for an electronic record schedule NARA (Job No.N1-15-02-3). This records schedule was created in 2002 which makes both the paper and electronic health record media neutral for future changes.

  1. DAMAGE TO AND UNAUTHORIZED DESTRUCTION OF RECORDS

a. VHA records shall not be disposed of without the proper authorization to do so. Federal law prohibits unauthorized destruction or mutilation of Federal records. The penalty for such acts is a $2,000 fine, 3 years in prison, or both pursuant to Title 18 United States Code 2071. Damage to, and unauthorized destruction of records is to be reported to the VHA Records Office immediately upon knowledge of such an act of destruction.

b. VHA officials must take measures to ensure that records are not disposed of improperly. Records are not to be removed from VHA custody or destroyed without regard to the requirements of this schedule or the GRS. When records are improperly disposed, NARA regulations and VA policy require the submission of a report to NARA. The report must include the record description, volume, date of incident, etc. Specific reporting requirements are contained in NARA regulations, Title 36, Code of Federal Regulations, Part 1228, Disposition of Federal Records, and VA Handbook 6300.1, Chapter 6., Records Management Procedures.

  1. RECORDS FREEZES/LITIGATION HOLDS

a. Records freeze: Records whose scheduled disposition has been temporarily suspended because of special circumstances that alter the administrative, legal, or fiscal value of the records.

b. Litigation hold: The Office of General Counsel (OGC) may periodically issue a litigation hold or moratorium on the disposition of certain records because the records may be potentially responsive or helpful in ongoing or pending litigation (lawsuits).

c. A "hold" is simply the implementation of a litigation hold notice issued by an OGC Office. Upon receipt, the records manager must suspend the normal disposition cycle of the records listed in the hold notice to prevent their early/premature disposal. Holds are placed on records in an agency's physical custody.

d. A "freeze" is created when the records manager receives a hold notice for records not in the agencyÕs physical custody but in the custody of the VA Records Center and Vault (RC&V), a Federal Record Center (FRC), or a commercial records storage facility. The Facility Records Manager would ask NARA to create a freeze to halt premature disposition of the records. Since most litigations deal with relatively current agency activity, the number of freezes is significantly smaller than the number of holds since the agency still has physical custody of most records affected by holds.

e. Upon receipt of a hold notice the records manager should initiate a freeze on any off-site records in conjunction with the hold placed on the on-site records in physical custody. This ensures that any potentially responsive record is preserved regardless of its physical location.

f. The Office of General Counsel maintains a list of litigation holds at the following website: OGC Litigation Share Point: https://vaww.ogc.vaco.portal.va.gov/litigation/Lists/active/AllItems.aspx

g. Additional information may be found at the following NARA website: http://www.archives.gov/frc/arcis/freeze-faq.pdf

  1. VITAL/ESSENTIAL RECORDS

Vital/Essential records are defined as essential records needed to maintain the continuity of Federal government activities during and following a national emergency or a technological or natural disaster and to protect the rights and interests of VA beneficiaries and employees. Additional information can be found in VA Handbook 6300.2.

  1. PERSONAL PAPERS

Personal papers consist of documents that relate only to an individualÕs personal affairs and do not affect the conduct of government business. Examples of personal papers are diaries, journals or other personal notes that are not created in the process of transacting government business. Personal papers may be disposed of in accordance with the ownerÕs preference. Note: Personal notes included on an official calendar or files are subject to official records authorities.

  1. TERMINATION OF OFFICE/SERVICE AND DEACTIVATION OF FIELD FACILITY

a. Specific records management procedures are to be followed when terminating an office/service or deactivating a field facility. The procedures are contained in VA Handbook 6300.1. It is important to follow these procedures to prevent the loss or unauthorized destruction of VHA records.

b. Once it has been determined to abolish an office/service or to deactivate a field facility, the office or facility records manager is to be consulted so that certain measures are taken to prevent the premature destruction of records. An evaluation is to be conducted to determine those records that are eligible for immediate destruction, identify records that are to be transferred to the successor office/service or facility, identify records that are eligible for transfer to a records storage facility, and identify records of permanent value to be offered to the NARA. Records are not to be disposed of without proper authority to do so.

  1. DEPARTMENT OF VETERANS AFFAIRS (VA) POLICY

a. VA Directive 6300, Records and Information Management, provides the policy for records and information management.

b. VA Handbook 6300.1, Records Management Procedures, specifies procedures for implementing the records management program.

c. VA Handbook 6300.2, Management of the Vital Records Program, implements the VA Vital Records Program which is an integral component of the VA Emergency Preparedness Plan.

d. VA Handbook 6300.8, Procedures for Shipment of Records to the RC&V in Neosho, Missouri, provides procedures for transferring records to the RC&V.

PART THREE

CHAPTER 6: HEALTHCARE RECORDS (6000-6999)

6000

Health Information Management (HIM) Service

6000.1. Health Records Folder File or CHR (Consolidated Health Record).

This records series contain all professional and administrative material necessary to document the episodes of medical care and benefits provided to individuals by the VA health care system.

a. Health Records Folder. This file constitutes the active medical or clinical records segment of the Consolidated Health Record. It completely documents diagnostic examinations and definitive medical, surgical, psychiatric, and dental care or treatment rendered a patient at a VA health care facility or at VA expense. It contains in written and graphic form the diagnostic; treatment and sociological information compiled by various members of the medical care team who participated in the care of a patient during one or more courses of treatment. In addition, it is intended to meet the legal, administrative, teaching and research needs of the VA medical staff, and provides a means of studying and evaluating the type of care rendered. VA and other monetary benefits are sometimes decided by use of information from the Health Records Folder.

Temporary; retain in VA health care facility until 3 years after last episode of care, and then convert to an inactive medical record. ( N1-15-91-6, Item 1a)

b. Administrative Records Folder (Correspondence Folder). This file constitutes the active administrative records segment of the Consolidated Health Records. It contains documentation of the patientÕs legal eligibility for VA medical benefits and the administrative documents relating to various episodes of hospital, nursing home, domiciliary, or outpatient care furnished at VA health care facilities.

Retain in VA health care facility along with the Health Records Folder until 3 years after the last episode of care,

and then convert to an inactive Medical record. (N1-15-91- 6, Item 1b)

c. Perpetual Medical Record. This record was created by extracting certain documents from the Consolidated Health Record (clinical and administrative segments) after a 3-year period of inactivity from the date of discharge or release of patient from the last episode of care. It contains the following basic medical and administrative records for each episode of care:

Application for medical benefits, narrative treatment summary (or equivalent), record of hospitalization (or equivalent), operation report and tissue examination report for each episode of care (if applicable). It also contains records relating to release of information, requests to amend records, records of denied access or disputes as required under the Privacy Act of 1974, and certain Ionizing Radiation and Agent Orange records.

Temporary; retire to records storage facility for storage. Retain at facility for the remainder of their respective retention period, then destroy at facility if not recalled along with the Inactive Health Record counterpart. If recalled, the Inactive Health Record counterpart must be recalled also so that the records can be converted into a Health Records Folder File. If the records are recalled, the retention period begins anew. (N1-15-91-7, Item 1)

[NOTE: This series has been phased out as a records series. Disposition schedule is for existing perpetual medical records. (N1-15-91-6, Item 1c)]

d. Inactive Health Record. This record contains all material relating to various episodes of hospital, nursing home, domiciliary, or outpatient care provided by VA health care facilities. It also consists of an application for medical benefits, narrative treatment summary (or equivalent), record of hospitalization (or equivalent), operation report, tissue examination report, electroencephalograph reports, electrocardiograph reports, autopsy report (if applicable), FOIA and PA related records, certain Ionization Radiation and Agent Orange records, and other related administrative and medical records.

Temporary; retire annually to the records storage facility. If not recalled by the accessioning facility for reactivation, destroy by WITNESS DISPOSAL72 years after retirement (75 after the last episode of care). (N1-15-91-6, Item 1d)

6000.2. Electronic Health Record (EHR).

a. Input

(1) Paper Source Documents.

(a) Hardcopy version of information manually inputted into the Electronic Health Record System (EHRS).

Temporary; destroy after verification of accurate entry of information into EHRS. (N1-15-02-3, Item 1a)

(b) Hardcopy version of information scanned onto optical disk or other magnetic media.

Temporary; destroy after verification of accurate scan onto optical disk or other magnetic media. (N1-15-02-3, Item 1b)

(2) Interim Electronic Source Information. Electronic version of source information obtained from other electronic databases, optical disk, or other magnetic media not considered as part of the consolidated patient medical record. May include information generated electronically by medical equipment.

Temporary; destroy/delete after migration of information to another electronic medium. Destruction of interim version of information is not to occur until it has been determined that the migrated information represents an exact duplicate of the previous version of the migrated information. (N1-15-02-3, Item 2)



b. Electronic Final Version of Health Record.

Final, consolidated, electronic version of a Patient Medical Record. Includes information migrated from interim electronic information systems, electronic medical equipment, or information entered directly into the patient medical record information system. May be stored on optical disks or other magnetic media.

Retain 75 years after the last episode of patient care. (N1-15-02-3, Item 3)



c. Output.

(1) Output in Electronic Form may include electronic display versions of patient orders, operation reports, health summaries, etc., and other documents associated with patient medical records.

Temporary; destroy/delete when no longer needed for administrative or clinical operations. (N1-15-02-3, Item 4)

(2) Output in Paper or other Hard Copy Form (may include output consisting of printed hardcopy patient medical records).

Temporary; destroy when no longer needed for administrative or clinical operations. (N1-15-02-3, Item 5)

d. Documentation. May include data dictionaries, field layouts, data entry instructions, and other manuals in paper and electronic form.

Temporary; destroy/delete when superseded or obsolete. (N1-15-02-3, Item 6)

e. Word Processing and Electronic Records. Superseded by General Records Schedule 4.3, Item 040 (SIC 2200.4).

[NOTE: any item, scanned into the Patient Electronic Health Record regardless of origination will take on the records disposal schedule of the electronic record. Examples are: immunization or other healthcare treatment from non-Veterans Health Administration provider after review of relevanceÕs by a VA provider.]

6000.3. Application for Medical Benefits

(Applicants Not in Need of Care File).

??Rejected applications for hospital treatment, domiciliary care, and related material not resulting in a treatment or member status. ??Rejected applications for outpatient dental treatment and found not to be in need of care. ??Rejected applications for outpatient treatment and found not to be in need of care.

Temporary; destroy after 2 years applications dated prior to September 24, 1969. Rejected applications initiated after September 24, 1969, will be filed in the patientÕs health records folder, if one exists within the facility or a health records folder will be created. (II-NN-3293, Item 1)

6000.4. Application for Medical Benefits (Transfer-Out

File).

Record of applications for medical benefits transferred to other VA facilities.

Nonrecord; destroy after 1 year.

6000.5. Privacy Complaint Files.

Records relating to the general agency implementation of HIPAA and, the Privacy Act, including notices, memoranda, routine correspondence, and related records. The files consist of complaints, concerns, and issues alleging a violation of the Privacy Act.

Temporary; cut off closed files at the end of the fiscal year. Destroy 6 years after cut off. (N1-015-08-1)

6000.6. Electronic Tracking System Files.

Electronic complaint files created to produce a tracking system such as the Privacy and Security Event Tracking System (PSETS) which is retrievable by a number. The files are used to track any grievance concerning an actual or suspected breach of privacy of personal information.

Temporary; delete files 6 years after corresponding case file is closed. (N1-015-08-1)

6050

Vet (Outreach) Center Records

6050.1. Outreach Counseling Folder File.

a. Psychological Counseling. Records consisting of important counseling-related material from the

counseling staff and significant psychological testing documents.

Temporary; retain in Vet Center until 5 years after the last episode of care, then retire to FRC. Destroy at FRC after 45 years. (N1-15-94-6, Item 1)

b. General Administration. Records consisting of General Administration Processing records, such as referrals, notes, and similar material where non- counseling services were provided.

Temporary; destroy when no longer needed. (N1-15-94-6, Item 2)

6100

Nursing Service

6100.1. Twenty Four (24) Hour Report File.

Twenty Four (24) Hour reports of patientÕs condition and nursing unit activities.

Temporary; destroy after 45 days. (II-NN-3426)

6100.2. Alcohol and Narcotics Record File.

Alcohol and narcotics record where all items were dispensed on the ward. Alcohol and narcotics inventory and certification records. Temporary; destroy after 2 years. (II-NN-3426) [NOTE: After completion of the monthly alcohol and narcotics ward inspection, these records may be sent to the inactive records storage area pending expiration of the retention period.]

6100.3. Community Nursing Program File.

Copies of nursing care referral forms, copies of requests for community home nursing care, service connected (SC), copies of requests for community home nursing care non- service connected (NSC), and related material.

Temporary; destroy after 30 days. (II-NN-3426)

[NOTE: The copy returned from the community-nursing agency is filed in the patientÕs medical record.]

6100.4. Detail Sheet File.

Detail sheets for identifying closed ward patients upon departure and return to ward.

Temporary; destroy after all listed patients have been returned to the ward or otherwise accounted for. (II-NN- 3225)

6100.5. Medication Card File.

Cards indicating types of medicines ordered by physicians and used by nurses for reference in preparation, administration, and recording of the medication.

Temporary; destroy after medicine was discontinued. (II- NN-3426)

6100.6. Patient Count File.

Patient count forms used to identify closed ward patients at change of tour of duty.

Temporary; destroy 30 days after form is completed. (II- NN-3426)

6100.7. Procedure Card File.

Cards outlining care and treatment for certain diseases and conditions.

Temporary; destroy when superseded by a new procedure. (II-NN-3426)

6100.8. Daily Assignment File.

Daily assignments of Nursing Service personnel. Temporary; destroy after 14 days. (II-NN-3426) 6100.9. Fee Basis Nurses File.

Copies of authorizations and invoices for medical service, individual record of visiting staff, visit record, applications for nurses in VHA, and related material.

Temporary; destroy 3 months after termination of service. (II-NN-3426)

6100.10. Volunteer Worker File.

Volunteer worker information card.

Temporary; destroy 6 months after volunteer ceases to work for Nursing Service and after and after report has been made as to the number of hours worked. (II-NN-3426)

6100.11. Tour of Duty Record File.

Tour of duty records of Nursing Service personnel. Temporary; destroy after 30 days. (II-NN-3426) 6100.12. Monthly Report of Restraint and Seclusion.

Information such as the patientÕs name, name of physician who ordered the type of restraint or seclusion action, type of restraint or seclusion, time of action, description of patientÕs behavior, etc.

Temporary; destroy after 2 years or after purpose has been served, whichever is sooner. (N1-15-95-3, Item 1)

6110

Social Work Service

6110.1. Patient Index File.

Social Work Service Data Cards or other automated Data Processing (ADP) generated listings of individual veterans, including basic identifying data.

a. Transfer active cards to inactive section after case is closed.

b. Destroy inactive cards after 6 years of social work inactivity and after discharge of patient. [NOTE: When a case is reopened before the end of 6 years, the information on the old cards will be brought forward to the new card and the old card(s) destroyed immediately.]

c. Destroy no activity cards immediately upon discharge of patient. (II-NN-3270)

6110.2. Social Work Clinical Working File.

Copies of social work reports, working papers, treatment and progress notes and related material

Nonrecord; destroy after purpose has been served.

6110.3. Social Worker Index File.

Copies of Social Work Service Data cards used as an index to the social work cases including ADP generated listings and/or Patient Data Code Sheets.

Temporary; destroy after case is closed and after preparation of necessary reports and summaries. (II-NN- 3270)

6110.4. Community Placement (Foster Home) Facilities File.

Application for participation in Community Placement Program, Correspondence to and from VA and Community placement facilities and related material.

Temporary; destroy approved applications 1 year after home withdraws from program. Destroy disapproved applications after 5 years. (II-NN-3270)

6110.5. General Resource File.

Records of information of health, welfare, legal, and financial resources for veterans and their dependents. Brochures, pamphlets, etc., and related material.

Temporary; destroy when obsolete or rescinded. (II-NN- 3270)

6120

Rehabilitation Medicine Service

6120.1. Patient Index Card and Attendance Record File.

Index card and attendance records indicating patientÕs name, diagnosis, treatment and record of attendance in Physical Medicine and Rehabilitation Service by patients treated. Information is used for readmission purposes in the event the patient returns for treatment, and for administrative and reporting purposes.

Temporary; destroy 2 years after discharge patient. (NI-15- 87-4, Item 9)

6120.2. Rehabilitation Medicine Patient Folder File.

Copies of various clinical records and related documents used to record treatment and services provided to patients are combined in this file upon completion of treatment.

Temporary; destroy 2 years after discharge of patient, or when no longer needed by Chief, Physical Medicine and Rehabilitation Service (unusual or exceptional cases only), whichever is later, and after record of treatment has been filed in the Health Records Folder File (or Consolidated Health Record). (NI-15-87-4, Item 10)

6120.3. Volunteer Workers Record File.

Volunteer workers information card.

Temporary; destroy 6 months after volunteer ceases to work for the service. (II-NN-3270, Item 26)

6200

Surgical Service

6200.1. Operation Log File.

Operation logs, which indicate type of operation, date, patientÕs name, surgeon, assistant scrub nurse, sponge count, anesthetist, agent, method, pre operation and post operation diagnoses, complications, and other information.

Temporary; destroy after 20 years. (N1-015-94-2, Item 1)

6200.2. Schedule of Operation File.

Workload data consisting of the date the surgery was performed, members of the surgical and nursing teams, and other information pertaining to the surgery of a patient. Temporary; destroy after 3 years. (N1-015-94-2, Item 2) [NOTE: Duplicate files are destroyed when no longer needed for reference purpose.]

6200.3. Mechanical Circulatory Assist Device (MCAD) Tracker. The MCAD tracker enables the National Surgery Office to fulfill the following responsibilities stipulated in VHA Directive 2012-033 Heart Failure Treatment Utilizing a Ventricular Assist Device or Total Artificial Heart: Patient Selection and Funding:

??Establishing a database for tracking Veterans who underwent the implantation of a mechanical circulatory assist device (either a ventricular assist device [VAD] or a total artificial heart [TAH]). ??Monitoring patient outcomes ??Administering and providing timely distribution of VHA Central Office special purpose funds to an approved in-house VHA cardiac surgery program or an approved VHA heart transplantation program for the care and treatment of Veterans receiving a VAD or TAH.

Temporary; cutoff at end of CY. Destroy 20 years after cutoff. (DAA-0015-2016-0006-0001)

6200.4. Transplant Referral and Cost Evaluation/Reimbursement (TRACER).

TRACER is a web-based application that enables (a) VA medical centers to enter referrals for Veterans who may require a solid organ or bone marrow transplant (b) VA transplant centers to review referrals and enter decisi on s reg ar ding th e Veter a n Õs elig ibil ity for further transplant evaluation; (c) enter transplant procedures and Veteran lodging costs for reimbursement by the National Surgery Office.

Referral Process: VA medical centers ??Provide information about the Veteran being referred for transplant evaluation (e.g., demographics, type of transplant desired, VA transplant center desired, names of referring physician, and date of VACO Transplant Referral NoteÓ in CPRS). ??Complete the electronic organ-specific transplant checklist ??After referral is submitted in TRACER, the VA transplant center of choice receives an email notification of the referral. ??The VA transplant centers reviews the referral in TRACER and the VACO Transplant Referral Progress Note in CPRS using VistA Web ??The VA transplant center enters a decision (reg ar ding the Veter anÕ s eli g ibil ity for furthe r transplant evaluation) into TRACER o VATC referral decisions are expected within 5 business days for stable patients, 48 hours for emergency patients.

After the VATC enters the decision, the referral submitter and members of the Referring Center Notification Group receive an email notification with link to the referral decision and next steps. TRACER also enables VA medical centers to re-submit referrals, request a second opinion by a different VA tran spl ant c ent er, a nd s u b mit a n Ò AppealÓ to th e Transplant Surgical Advisory Board. TRACER enables VA transplant centers to electronically transfer patients from one transplant center to another.

Temporary; cutoff at end of CY, destroy 20 years after cutoff. (DAA-0015-2016-0006-0002).

6200.5. Referral Review Process: VA Transplant Center. After referral is submitted in TRACER, the VA transplant center of choice receives an email notification of the referral. 3. The VA transplant centers reviews the referral in TRACER and the VACO Transplant Referral Progress Note in CPRS using VistA Web 3. The VA transplant center enters a decisi on (r eg ar ding the Veter an Õs elig ibil ity for further transplant evaluation) into TRACER a. VATC referral decisions are expected within 5 business days for stable patients, 48 hours for emergency patients After the VATC enters the decision, the referral submitter and members of the Referring Center Notification Group receive an email notification with link to the referral decision and next steps. TRACER also enables VA medical centers to re-submit referrals, request a second opinion by a different VA transplant center, and submit an Ò Appe alÓ to the Tr an spl ant S urg ical Adviso ry Board. TRACER enables VA transplant centers to electronically transfer patients from one transplant center to another.

Temporary; cutoff at end of CY, destroy 20 years after cutoff. (DAA-0015-2016-0006-0003). 6200.6. Pre-Operative Case Management Tool. Before a provider can determine whether a patient is a candidate for surgery, the patient often needs a series of preoperative assessments and procedures. Because VA facility staff are discouraged from using independent mechanisms to track patients, as these may be perceived as unauthorized waitlists, the National Surgery Office (NSO) developed the Pre- Operative Case Management (POCM) tool to track patientsÕ required pre-operative consults, diagnostic tests, and procedures before a determination of surgical candidacy can be made. The POCM tool is not a waitlist nor intended to be a system of record, and it does not replace existing VA scheduling or medical record systems. Use of this tool is optional.

POCM coordinators and/or providers at a facility enter patients and workups ordered by the clinician that they anticipate may delay the determination of surgical candidacy. Once all workup items are completed, POCM alerts designated personnel the patient information is ready for review. If no additional workups are necessary, surgical candidacy determination is noted and the patient status is set to complete.

Patient workup information is maintained in a SharePoint list for presentation to POCM users while workups are pending. All patient and workup information is also written to a SQL database to provide PHI blinded reporting capabilities. After 30 days, patient data with a Complete status is removed from the SharePoint view.

Temporary; cutoff at end of CY, destroy 10 years after cutoff. (DAA-0015-2016-0006-0004).

6200.7. Continuous Improvement in Cardiac Surgery Program (CISCP) Database.

Monitor and report cardiac surgical procedures performed in any VHA cardiac surgical program using unadjusted and risk-adjusted outcomes data.

Temporary; cutoff at end of CY. Destroy 20 years after cutoff. (DAA-0015-2016-0006-0005).

[NOTE: In 2009, NSQIP and CICSP were combined to form the VA Surgical Quality Improvement Program. (VASQIP) (see VASQIP below)]

6200.8. National Surgical Quality Improvement Program (NSQIP) Database.

Purpose: To monitor and report non-cardiac surgical procedures performed in any VHA surgical program using unadjusted and risk-adjusted outcomes data.

Temporary; cutoff at end of CY, destroy 20 years after cutoff. (DAA-0015-2016-0006-0006).

6200.9. VA Surgical Quality Improvement Program (VASQIP) Database.

Monitors and reports risk-adjusted (O/E) surgical outcomes and actual (unadjusted) mortality for major surgical procedures performed at each VA medical center for all operations combined and for each surgical specialty on a quarterly basis and for the rolling year. An analysis and review of the VA medical center structure and process will be prompted based upon the reporting of a statistically high O/E ratio. The VASQIP uses logistic regression analysis to calculate the probability of death or complication for each patient in the database, based on the patient's preoperative risk factors. These probabilities can then be summed for all surgical procedures performed by the VHA surgical programs to arrive at an expected number of events (mortality, morbidity) for all operations including the following surgical specialties: cardiac surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. The observed number of events (O) divided by the expected number of events (E) produces the O/E ratio for the procedures performed at any single VA medical center. As reference, an O/E ratio of 1.0 indicates that the observed number of events is equal to the number of events expected based upon the patient mix in a given specialty at that VA medical center.

Temporary; cutoff at end of CY, destroy 20 years after cutoff. (DAA-0015-2016-0006-0007).

6200.10. Ophthalmic Surgical Outcome (OSOD) Database.

Monitor and report ophthalmic procedures performed in a 5-site pilot group of VHA surgical programs to evaluate functional outcomes and assess feasibility of data capture at all VHA surgical programs.

[NOTE: Data within the OSOD database reflect cataract surgeries for April 2009 through September 2011 at 5 pilot sites.]

6270

Spinal Cord Injury Service

6270.1. Spinal Cord Dysfunction Registry.

Information collected includes patientsÕ names, social security numbers, dates of birth, registration dates, information about whether patients are receiving services from VAÕs spinal cord system of care, neurologic level of injury, etiology, and other related spinal cord injury information.

a. Master Files (centralized database).

Temporary; cutoff at the last unique patient entry or the death of a particular patient. Delete 75 years after cutoff. (N1-015-05-1, Item 1)

b. Local Files (SCI centers and clinics).

Temporary; delete when replaced by a subsequent file or 75 years after date of last activity for a particular patient. (N1- 015-05-1, Item 2)

c. Backup Files.

Temporary; delete when master files have been deleted or replaced with a subsequent backup file. (N1-015-05-1, Item 3)

d. Input Records.

Temporary; destroy after data have been entered into local files. (N1-015-05-1, Item 4)

e. Output Records.

Temporary; destroy when no longer needed for administrative, legal, audit, or other operational purposes. (N1-015-05-1, Item 5)

f. Documentations.

Temporary; destroy or delete when replaced or superseded. (N1-015-05-1, Item 6)

g. Electronic copies of mail and word processing applications.

Temporary; cutoff at end of CY, destroy 7 years after cutoff. (DAA-0015-2016-0006-0008).

(1) Copies maintained by individuals in personal files, personal electronic mail directories, or

other personal directories on hard disk or network drives, and copies on shared network drives that are used only to produce the recordkeeping copy.

Temporary; destroy or delete within 180 days after the recordkeeping copy has been produced. (N1-015-05-1, Item 7a)

(2) Copies used for dissemination, revision, or updating.

Temporary; destroy or delete when dissemination, revision, or updating is completed. (N1-015-05-1, Item 7b)

6270.2. Report of Patients with Spinal Cord Injury or Disease Ð PatientÕs File. (see note below)

Quarterly reports of admission and discharge data used to project workload trends monitor and compare workloads of hospitals designated as spinal cord injury centers.

Temporary; destroy after 5 calendar years. (NCI-15-85-3, Item 2)

[NOTE: Report discontinued on October 1, 2001.]

6270.3. Spinal Cord Injury Home Care Unit Quarterly Activity Report File. (see note below)

Quarterly activity reports used to project workload trends monitor and compare workloads of home care units.

Temporary; destroy after 5 calendar years. (NCI-15-85-3, Item 3)

[NOTE: Report discontinued on October 1, 2001.]

6300

Neurology Service

6300.1. Electroencephalograph (EEG) Records File.

A typical EEG detects electrical impulses of the brain and records them on long sheets of graph paper (tracings). A single EEG procedure can consists of at least 120 sheets of graph paper. VA form 10-2614Õs, Electroencephalographic Request and Report (interpretation), is used to record the results of a tracing.

a. Electroencephalograph Tracing.

Temporary; cutoff at the end of calendar year in which EEG record was created, destroy 7 years after cutoff. (N1- 15-97-1, item 1)

b. Electroencephalograph Request and Report (interpretation). VA Form 10-2614, Electroencephalograph Request and Report, used to record the results of an EEG tracing.

Temporary; cutoff at end of calendar year in which VA form 10-2614 was interpreted by provider, destroy 30 years after cut off. This schedule only applies to VA form 10- 2614 maintained in EEG Office. (N1-15-98-01, item 1)

[NOTE: Most EEG are scanned into VistA/CPRS as a complete Electronic Health Records (EHR). Once the VA form 10-2614 is placed into VistA/CPRS it takes on the record retention schedule of the (EHR) of 75 yrs after last episode of care (series 6000.2 of this manual).]

6400

Mental Health and Behavioral Sciences Service

6400.1. Clinical Psychology Folder File.

Notes, psychological evaluations, recording sheets, psychological test material, and related material.

a. Clinical psychology folders used in research projects after discharge of the patient.

Unscheduled: do not destroy SF-115 pending from NARA.

 b. Clinical psychology folders NOT used in research projects after discharge of patient.

Unscheduled: do not destroy SF-115 pending from NARA.

6400.2. Mental Hygiene Folder File.

Detailed working noted on the clinic therapist, records of therapy sessions, psychological test books, protocols and other psychological data, trail visits notes, psychological evaluations, treatment and progress notes, neurological examinations, physical therapy examinations, hospital reports of examination, release of information documents, correspondence, and copies of initial, periodic, and closing reports which are files in the patientsÕ medical record folder file. Unscheduled: do not destroy SF-115 pending with NARA. [NOTE: In 1985 it was determined that the Mental Hygiene Folder become part of the patient paper Health Record. Legacy Mental Hygiene folders were inner-filed with the paper Health Records. When the Patient Electronic Health Records was created the Mental Hygiene

folders were already part of this record. The pending record schedule with NARA is for the Legacy Mental Hygiene folders that are found without a paper or electronic health record.]

6400.3. Psychology Test Data and Worksheet File.

Psychological test material, notes worksheets, and related materials.

Unscheduled: do not destroy SF-115 pending with NARA.

6400.4. Homeless Providers Grant and Per Diem Files.

Applications (initial and second), site designation, schematics drawings, data relating to homeless demographics, payment documents to grant recipients, supporting letters, general correspondence, and correspondence relating to inspections drawings.

a. Files relating to applications who were awarded vans. Temporary; destroy after 5 years. (N1-15-98-04, item 1a) b. Files relating to applicants who were awarded grants to construct, renovate, or acquire buildings for supportive housing or supportive services.

Temporary; destroy 10 years after the last grant payment has been issues. (N1-15-98-04, item 1b)

c. Files relating to applicants who receive per diem payment.

Temporary; destroy 10 years after last per diem payment has been issued. (N1-15-98-04, item 1c)

d. Electronic version of record created by electronic mail and word processing application.

Superseded by General Records Schedule 4.3, item 040 (SIC 2200.4).

6400.5. Unsuccessful Grant Application File.

a. applications, correspondence, and other documents pertaining to unsuccessful applications.

Temporary; destroy 2 years after the disapproval or withdrawal of the application. (N1-15-98-04, item 2a)

b. electronic version of records created by electronic mail and word processing application.

Superseded by General Records Schedule 4.3, item 040 (SIC 2200.4).

6500

Geriatrics and Extended Care

6500.1. Unsuccessful Grant Application Files.

Applications, correspondence, and other records relating to unsuccessful (rejected or withdrawn) applications for State Home Construction Grants.

Temporary; destroy 3 years after rejection or withdrawal. (I1-15-91-5, Item 1)

6500.2. Reserved.

6500.3. State Home Construction Grant Files.

Pre-applications, applications (SF 424s), technical reviews of design documents, environmental assessments, clearances for historic preservation requirements, and certifications of compliance with numerous Federal laws (Davis-Bacon Act, Rehabilitation Act, Civil Rights Act, etc.), bid tabulations, revised budgets based on bids, memoranda of agreements, substantive correspondence and other related documents

a. Hardcopy.

Temporary; destroy after microfilming and after the microfilm has been verified as an adequate substitute for the hardcopy (paper) files.

b. Master and Two Reference Copies.

Temporary; master and one reference copy maintained by the Office of Geriatrics and Extended Care are to be destroyed 20 years after completion of project. Reference copy transferred to the Office of Facilities will be destroyed 20 years after completion of project.

6600

Dental Service

6600.1. Beneficiaries Ledger Record File.

Ledger used to identify the removal of dental appliances when removed from mouths of NP patients at time of admission and to indicate beneficiaryÕs name, number and type of appliance.

Nonrecord; destroy 1 year after date of last entry.

6600.2. Dental Appointment Record File.

Ledger or book indicating daily appointments for patients for dental treatment and showing patientÕs name, time of appointment and type of work to be performed.

Nonrecord; destroy 1 year after last entry.

6600.3. Dental Laboratory Requisition and Work Record File.

Copies of instruction sheets to obtain fabrication of dental appliances from central dental laboratory and related material.

Nonrecord; destroy after patientÕs case is completed.

6600.4. Dental Card Index.

Dental Service index cards indicating patientÕs name, diagnoses, treatment, condition, etc., on current or recent patients receiving dental treatment.

Nonrecord; destroy after discharge if patient was not examined OR 6 months after discharge if patient was examined but not treated OR after 3 years if patient was treated or received x-rays.

6600.5. Dental Master Card File.

Detailed summary of dental services rendered to a patient in a VA health care facility; used as a ready reference on veterans treated in the dental clinic, for budget purposes, and for compiling statistics on patients treated.

Temporary; destroy 3 years after date of last activity. (NI- 15-87-4, Item 7)

6600.6. Dental X-Ray Film File.

Dental x-ray film, exposed.

a. Dental x-rays filed in the Outpatient Treatment Folder or in the Health Records Folder.

Temporary; retain until folder is converted to an Inactive Medical Record (3 years after last episode of care) then destroy. (NI-15-87-4, Item 8a)

b. Dental x-rays used for research and teaching p u rp o ses wh ich are n o t fil ed in the p ati en tÕs medical record.

Temporary; retain until purpose has been served or3 years after last exposure, whichever is whichever is longer, and then destroy. (NI-15-87-4, Item 8b)

c. All other original dental x-rays maintained at VA health care facilities.

Temporary; retain until 3 years after the date of last exposure, and then destroy. (NI-15-87-4, Item 8c)

d. Facsimile reproduction of dental x-rays.

Temporary; destroy when purpose has been served. (NI-15- 87-4, Item 8d)

[NOTE 1: VA x-ray films are currently disposed of by salvaging at the VA Supply Depot under the VA Precious Metals Recovery Program.]

[NOTE 2: Certain dental x-rays taken at VA health care facilities in support of veterans benefits claims are disposed of in accordance with the Veterans Benefits Administration RCS VB-1.]

6600.7. Laboratory Case Load Ledger File.

Ledger used to record all cases handled by the dental laboratory and to indicate date of receipt, name of patient, referring facility, laboratory case number, and description of case.

Nonrecord; destroy 1 year after date of last entry.

6600.8. Precious Metals Ledger File.

Ledgers containing a record of dateÕs precious metals were received from Supply Service and the combined gross troy weight of all gold received (excluding fabricated bars). Number of prefabricated gold bars received, date, name of patient and description of each appliance fabricated. Weight of platinum received, gross weight of all gold turned over to Supply Service. Unserviceable gold appliances retained by patients along with their signature.

Temporary; destroy 3 years after date of last entry. (35O-S- 61, Item 2)

6600.9. Precious Metals Issue Slip.

Copies of memorandums indicating amount of gold turned- in to Supply Service.

Temporary; destroy after 1 year. (350-S-247)

6600.10. Old Gold Turn-in File.

Correspondence and related papers on old gold turn-in. Nonrecord; destroy after 1 year.

6600.11. Precious Metals Record Card File.

Cards indicating a running record of each type of precious metal on hand and showing the amount issued and the balance on hand at all times

Nonrecord; destroy 1 year card has been filed and the balance brought forward to a new card.

6650

Medical video

6650.1. Medical Video Record;

Records such as; EEG video, Range of motion /physical Therapy, Endoscopy, or other video not scheduled elsewhere in the manual. The exception is where a NARA approved records control schedule already exists in RCS 10-1.

Destroy when 2 years old. (GRS 21, item 19) (N1-GRS-98- 2, item 40)

[NOTE: Cardiac Catheterization Film (Motion Picture) (see 7000, item 3) (N1-015-96-3)/ Echocardiogram Video Cassette Recording Tapes. (7000, item 4) (N1-015-07-1)]

[NOTE: If the 2 year record schedule above does not meet the record disposition needs then the VHA Program Office responsible for the videoÕs shall contact the VHA Records Officer, to submit a new records schedule to NARA for approval.]

6675

6675.1. Tumor Registry File Index Card and Folder File.

This file contains information on patients treated for tumors. It contains abstracts, inpatient information from the Medical Records Folder File, subsequent follow-up data (including that from private sources), and related material. This file is used for treatment purpose as well as research.

Temporary; destroy 75 years after date of last activity. (N1- 15-87-4 item 6)

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