Patient Record Flags (PRF) are advisories that authorized users place on a patient's chart to improve employee safety and the efficient delivery of health care. Each advisory or flag includes a narrative that describes the reason for the flag and may include some suggested actions for users to take when they encounter the patient. Other information displayed to the user includes the Flag Type, Flag Category, Assignment Status, Initial Assignment Date, Approved by, Next Review Date, Owner Site, and Originating Site. When assigning a flag, authorized users must write a progress note that clinically justifies each flag action.
Flags are defined in the PRF List Manager software either through a patch or by an authorized user. Once the flag definition exists, authorized users can use the following actions in the PRF software to assign and maintain the flag on a specific patient's record: new assignment, continue, inactivate, mark as entered in error, and reactivate.
To make flags widely available to VHA employees who interact with patients, Patient Record Flags are tied to the patient look-up. Whenever a user looks up a patient, the software checks to see if the patient's record has been flagged, and if a flag exists, the software displays the list of flag names.
To ensure that users notice them, CPRS uses a Patient Record Flags pop-up box. After a user selects a patient with an active flag assignment, CPRS pops up a dialog containing all flags for the patient. Users can review the flags or close the box. The rest of the patient record does not load until the user closes the PRF pop-up box. Once the rest of the record is loaded, users can view flags at any time using the Flag button or the Cover Sheet list of PRF displayed on the upper right of the Cover Sheet under Patient Record Flags.
Sites can help users notice the flags by using Patient Record Flags judiciously. Overusing these flags could make them cumbersome to users who might therefore choose to ignore them. Ignoring flags could put employees, other patients, and the health care environment at risk.
To avoid this situation, before placing a flag on a patient's record, sites must have in place a system for deciding when a flag is appropriate and when it will be reviewed. Sites should also have policies about how to handle questions about flags. To give sites some direction about implementing Patient Record Flags, VHA DIRECTIVE 2010-053, dated December 3, 2010, titled: Patient Record Flags has been issued.
Category I and Category II Flags
Patient Record Flags are divided into types: Category I (national) and Category II (local). Category I Patient Record Flags are the most critical and are transmitted to all facilities, ensuring that these flags are universally available. Category II Patient Record Flags are local only, belonging only to the site that created them; they are not shared between sites.
Category I or National Flags
Currently, the only Category I Patient Record Flag is a Behavioral flag for violent or potentially violent patients. The Office of Information created this flag to help VHA properly protect its employees and maintain a safe environment for health care. The Office of Information defines and distributes Category I flags through national patches and the definition of the flag cannot be edited by local sites.
Each Category I flag assignment to a specific patient's record is owned by a single facility. The facility that placed the Category I flag on the patient's record would normally own and maintain the flag. The site that owns the Category I flag is the only site that can:
· review whether to remove or continue the flag
· edit the flag
· inactivate the flag
· reactivate the flag
· mark the flag as entered in error
· change ownership of the flag
· enter a Patient Record Flag Category I progress note for the flag
However, ownership of a Category I flag assignment can be transferred. If a patient received the majority of care at a different VA facility than the one that assigned the flag, the site giving the majority of care could request that ownership of the flag be transferred to the that site. The owning site could then change the ownership to the second site through the PRF software in List Manager.
Category II or Local Flags
Category II flags are local. Each site can create and maintain its own set of local flags that are not transmitted to other sites. However, the purpose of Category II flags is similar to Category I--to provide important patient information to health care providers. For example, a site could create a Patient Record Flags Cat II - Diabetes flag or a Category II Infectious Disease flag.
In VHA DIRECTIVE 2010-053, dated December 3, 2010, titled: Patient Record Flags, VHA advised sites to create and use Patient Record Flags sparingly so that users will notice flags and pay careful attention to them. Creating a large number of flags for many different reasons might lessen the impact of flags and cause staff to miss important information. Both Category I flags and Category II flags require a progress note to document the reason for placing a flag on the patient's record.
Creating, Assigning, and Maintaining PRF
Some sites may have two different groups of users who work with Patient Record Flags: administrative users who create, maintain, and assign flags and the clinical users that document why the flag was placed on the patient's record. Authorized users can define Category II flags and edit their definitions. They assign and maintain the flag on a patient's record using the assignment actions in the PRF software through the List Manager interface: new assignment, continue, inactivate, mark as entered in error, and reactivate. (Additional documentation for PRF creation, assignment, and maintenance is available in the Patient Record Flags User Guide.)
Documenting PRF
With CPRS GUI v.26, each Patient Record Flag action (new assignment, continue, inactivate, reactivate, or mark as entered in error) must have a linked progress note that clinically justifies any action taken. Previously, each flag needed to have a progress note, but there was no link between the note and the flag action. Now when the user writes a PRF progress note, the user must link the note to a flag action. The note might also contain references to supporting documentation.
In each flag definition, the user must select the previously created PRF progress note title that will document the reasons for any flag action. This is referred to as associating a progress note title with a PRF. Before a title can be associated with a PRF, the title must be created either by a patch for a national flag or by someone at the site for a local flag.
For example, if a user were defining a Wandering flag in the PRF List Manager software, someone at the site must have already used TIU to create the appropriate note title in the correct document class. Then, the user defining the flag would associate a title such as, Patient Record Flag Category II - Risk, Wandering, by selecting that title from the list of available PRF progress note titles.
Once the flag and the progress note title are associated, when the user writing a new progress note selects a PRF progress note title, CPRS displays the flag actions on the selected patient and whether each action has been linked to PRF progress note (Yes or No). For the new PRF note, the user then selects the available flag action to create the link between the note and the flag action.
Note: There is a one-to-one correspondence between flag actions and progress notes. Each PRF action for a patient can only be linked to one progress note; each progress note can only be linked to one flag action.
Prerequisites to Writing PRF Progress Notes
Before users can write progress notes that document PRF, PRF progress note titles must be set up correctly. Each PRF progress note title must be associated with a specific flag definition, and users must be assigned to the appropriate user classes to write specific kinds of notes. Also, someone must have assigned the flag to the patient.
For users to write a progress note and correctly link the note to a flag action, sites must complete the following set up:
· To write a PRF note for a category I flag, the user must belong to the DGPF PATIENT RECORD FLAG MGR user class. Each site will be responsible for populating this user class.
· Because Category II Patient Record Flags are local, each site must determine if the site will create a user class and business rules to govern which users can write Category II PRF progress notes.
· The PRF note titles should follow the naming conventions described in the directive and be descriptive enough that users can tell which note title corresponds to which flag.
· The flag definition must contain the progress note title that documents actions for that flag--each PRF note title can only be associated with one flag.
· Category II PRF progress note titles must be in the Patient Record Flag Cat II document class under the Progress Notes document class to allow users to associate them with a PRF Category II definition. If the titles are not in this document class, they will not display when the user attempts to associate the title with a PRF Category II flag nor will CPRS get the information about which flags actions are linked. Progress note titles for Category I patient record flags are defined and associated by national patch.
PRF Note Titles
Currently, there is only one Category I flag: Behavioral. The Progress Note title for documenting this flag is "Patient Record Flag Category I".
To help sites that will be creating local Category II flags, four partially customizable Progress Note titles have been distributed:
· Patient Record Flag Category II - Risk, Fall
· Patient Record Flag Category II - Risk, Wandering
· Patient Record Flag Category II - Research Study
· Patient Record Flag Category II - Infectious Disease
Clinical Application Coordinators (CACs) can customize these titles by changing the text after the dash using TIU utilities. For example, the first title could be changed from "Patient Record Flag Category II - Risk, Fall" to "Patient Record Flag Category II - Behavioral, Drug Seeking" or other titles sites create.
CACs can also create their own titles, but the title must follow the naming convention "Patient Record Flag Category I - other text" where other text is the text specific to the local note title.
Linking PRF Notes to Flag Actions
In the CPRS GUI, users must link a PRF progress note to a flag action when the user writes a PRF note. This linking can also be done through the List Manager interface using TIU options. In the CPRS GUI's Progress Note Properties dialog, when a user selects a Patient Record Flag progress note title, CPRS displays a list of flag actions to which the note can be linked at the bottom of the dialog. This list shows all the actions for the flag and whether each action has been linked.
For progress note titles that document the justification for a patient record flag, users will be able to link the progress note to the specific flag action they are documenting. The example shown here is of a Category I PRF progress note and the Continue action to which the user would choose to link.
Note: For PRF notes, users must select a flag action to link the note to before they can write the note--the same way users link a note with a consult. CPRS will not allow the user to write the note unless an unused flag action is selected. If the user does not select a flag action, CPRS displays a dialog that states, "Notes of this title require the selection of a patient record flag action".
When the user select a PRF progress note title, CPRS displays this list of note actions only if sites have done the correct set up as described earlier. The user must then pick the action (new assignment, inactivate, reactivate, continue, or entered in error) that the note is documenting.
If a user is viewing a note and wants to see to which PRF action the note is linked, the user can select View | Details on the Notes tab. The details include the flag name, the date, and the action that was linked.
If a user writing a new progress note chooses a PRF progress note but CPRS does not display any flag actions for linking, one of the following has probably occurred:
· The flag has not been assigned to this patient yet.
· The user has selected the wrong progress note title for the flag.
· If it is a Category I flag, the site may not own the flag.
Marking PRF as Entered in Error
Marking PRF as entered in error terminates the flag's display in the patient's record. However, if there was a progress note linked to the flag, the progress note is still in the patient's record. If the flag was entered in error, an authorized TIU user should retract or retract and reassign the linked progress note.
Note: Users should be aware that although the flag does not display, a history of this flag is kept in the Patient Record Flag software and users can reactivate the flag. To prevent users from entering notes on previous, inaccurate PRF actions, all previous PRF actions are hidden when a flag is marked as entered in error.
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