Record keeping in VA hospitals - what to do with test data?

[DrGero]

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I've been advised previously by my Service Chief that test data is not considered part of the official record and therefore I'm not required to retain it for the customary 7 years as I would the client's CPRS chart (which gets done automatically, obviously).

Which is good, because I work in a nursing home (CLC) and I don't have much space to do archiving. What I do is store the capacity assessments I can and data from patients that I've seen more than a few times for serial testing, but trash other stuff - I just don't have space for it.

I recently got a request from a neuropsych. clinic at another facility for test data on a patient I saw a few months ago. Unfortunately, his data didn't get retained. I feel kind of bad about that, although for the most part I did include a lot of the raw data in the assessment report in question - which I do because I know I can't keep data in many or most cases.

Anyways, I just wanted to double check. Do people think this is a reasonable way to deal with test data? Again, I keep some that I forsee might be involved in later litigation, or data from patients I've been doing serial testing with, but I don't keep most of it. Am I being ethical with my record-keeping? I'm wondering because, in the next building from me is the neuropsychologist for our site - and he keeps everything. But - he has an entire room filled with file drawers right next to his office.

Anyways, opinions from VA folks or people with some knowledge of issues involving record-keeping in an EMR world is welcome.

 

[Ollie123]

Depends on how exactly things are structured, and this could definitely be a pain in the butt if you had to do it yourself and don't have administrative staff who can take care of it, but if the problem is a lack of physical space, perhaps you could scan in the raw data and keep electronic backups? There are obviously some security issues that go along with that and not sure how the VA admin would feel about it (oh the paperwork...), but it was the first solution that came to mind. Sort of a do-it-yourself EMR.

Only on my mind because I have been obsessive scanning stuff in the last couple weeks. I basically keep all of graduate school in electronic formats because, frankly, I lack the space for all that paper, and even if I had the space for it, I lack the organization to actually find any of it.

 

[DrGero]

I just sent my service chief an email on this. I really just want to make sure I'm doing ethical record keeping and I'm not doing "record abandonment." If I need to find more space to archive my test data, then fine. Or, if I can continue to selectively cull test data, that's OK too - I just need some more guidance on this.

 

[DrGero]

Turns out I should have been keeping all the test data. My SC didn't seem too bothered by the fact that I hadn't done so for about half the cases I've accumulated over the past three years, and reassured me that he was certain my practice hadn't been compromised.

He also said it's not exactly clear sometimes what to do as a psychologist when you've got the VA actively discouraging people from retaining records outside of CPRS. Oh well, live and learn.