VA Mid South Healthcare Network (VISN 9)

Report ID: SPE000000070166, U.S. Department of Veterans Affairs

Reported Entity: VISN 09 Mountain Home, TN

Issue:

Per the Report of Contact (ROC) supplied by the Chaplain today: "I came into station on Saturday afternoon, 12/24/11 expecting to find my log book on the computer desk in the library located in the chaplain's office. Both library door and chaplaincy door were locked. My log book was not anywhere in the office. I cannot rule out the possibility that my memory is in error and that in fact the log book was not left in the library. The contents of the log book included the last name, last 4, and room number of every patient that I have visited since 10/11/11 through 12/23/11. With only a few exceptions, these were patients in the Nursing Home but did include some names and information from inpatients. The information included cover sheet personal data as well as my notes on the content of each visit/spiritual assessment, including some medical information. I am estimating that it would probably include 350 entries, and probably about 175 names. Update: 01/03/12:An issue brief was completed per the Chaplain Service. A report was run for all of the patients seen by this Chaplain and per Chief Chaplain Service the update on the number of Veterans is that, "An estimated 79 patients may have been in the notebook."01/06/12:Seventy-nine patients will be sent notification letters.

Outcome:

Intern was terminated from training program. All Chaplain Service personnel received additional inservicing on protecting PHI and PII data; prohibition on use of log books, note books and other written/hardcopy records; and specific guidance on prompt and proper disposal of written materials created as memory aids prior to entry of progress notes and workload data in CPRS/Event Capture systems