Review of Primary Care Providers’ Completion of Electronic Health Record Documentation at the VA Augusta Health Care System in Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection of the VA Augusta Health Care System (system) to evaluate whether system leaders maintained oversight of primary care providers’ processing of electronic health record view alerts, ensured timely completion of documentation following patient visits, and acted promptly on state licensing board reporting requirements after removing a provider from employment.

System policy required primary care providers to process view alerts within 7 days. The assistant chief of primary care relied on a dashboard that displayed alerts older than 21 days, which limited effective oversight. In November 2025, the chief of primary care implemented corrective actions, including review of a daily report listing alerts older than 7 days and providing verbal counseling when alerts remained unprocessed beyond 7 days.

The Veterans Health Administration (VHA) requires providers to complete progress note documentation within 7 calendar days of patient visits. System leaders did not effectively monitor compliance before July 2025. Without complete documentation, patient electronic health records do not accurately reflect the care provided or any necessary follow-up actions, increasing patient safety risks.

The OIG found that leaders did not initiate state licensing board reporting within 7 business days after removing a primary care provider in 2024 for not meeting accepted standards of practice, as required by VHA. Facility leaders initiated the state licensing board reporting process during the OIG’s June 2025 site visit. Timely reporting of providers helps alert potential employers to concerns about a provider’s practice.

The inspection resulted in one recommendation. In response, the Veterans Integrated Service Network Director reported plans to ensure relevant system staff and leaders are trained on state licensing board reporting requirements.