Across its nationwide network, the Department of Veterans Affairs (VA) has developed a system of Patient Record Flags (PRFs) to identify veterans whose clinical or behavioral profile may carry elevated risk to themselves, to other patients, or to staff. Originally designed for issues like assaultive behavior or self-harm risk, the PRF system now sits at the intersection of patient safety, care coordination and rights protection.
Under VHA Directive 1166, a PRF may only be placed when (1) it is necessary for VA staff to know, at the initial moment of engagement, information about the patient’s behavior or safety status; and (2) the identified risk to the patient or others outweighs the privacy concerns triggered when the flag appears anytime the electronic health record (EHR) is opened.
How the Flags Work
The VA currently operates three nationally standardized flags: the Behavioral PRF (used for disruptive or threatening conduct), the High Risk for Suicide PRF (HRS-PRF), and the Missing/Wandering PRF. These nationwide designations are supplemented by additional, locally developed flags at some facilities to address site-specific needs.
According to VA Press Secretary Pete Kasperowicz, the flag system is designed to ensure that “additional treatment or care that the patient may need is prioritized.” While the specifics of each flag vary, all are governed by the same review requirements: they must be reassessed at least once every two years – or sooner if the veteran’s circumstances change – and veterans can request modification or removal under the procedures outlined in Directive 1166.
As of November 2025, roughly 20,000 active PRFs were recorded across the Veterans Health Administration (VHA). However, VA officials say the department currently has no centralized data on how often flags are removed, underscoring the system’s transparency and consistency challenges.
Once placed, a PRF travels with the veteran’s health record across all VA facilities. That means any outpatient or inpatient encounter may trigger the alert.
According to the PRF User Guide, “Each PRF 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.”
The narrative attached to the flag explains the reason (for example, “previous assaultive threats to staff”), and may suggest recommended actions or protocols (e.g., call VA police immediately). Importantly, the guide explicitly states that the purpose is not stigma or punishment: “PRFs are not intended to stigmatize or discriminate… rather it is to protect VHA staff and patients to ensure efficient delivery of health care.”
Rationale and Benefits
VA facilities serve a population with elevated risk in domains such as mental health issues, high-risk substance use, homelessness, traumatic brain injury, and more. The PRF mechanism helps site-based staff see, at a glance, patient risk. That can reduce surprises (for example, a veteran with a known history of assault sent to a general clinic without alerting staff) and support assignment of enhanced care or security coordination.
Because all facilities share the flag, a veteran who rotates between locations carries the same caution label, which helps prevent “surprise encounters” and improves continuity. The new 2023 directive strengthened review cycles and ownership responsibilities, signaling the VA’s emphasis on safety and reliability in the system.
Challenges and Concerns
The PRF system also brings controversy and risk. One major tension is privacy: once a flag is placed, anyone accessing the patient’s EHR may view it, even if that person does not “need to know” under usual health-privacy principles. The August 2013 user guide says: “The use of PRF can be ethically problematic … First, a PRF stigmatizes patients … Second, a PRF compromises privacy because it reveals private patient information to anyone who opens the patient’s chart.”
Veterans may feel labelled or treated differently, staff may rely on the flag and overlook changes in behavior, and there’s always the risk that a flag lingers longer than its justification. The VA aims to address this via review cycles and inactivation policies, but the implementation varies by facility.
Another challenge is balance: the flag is meant to aid care, not to trigger exclusion or denial of service. The directive stresses that “a PRF must be placed only after the appropriate assessment and evaluation” and “be entered only by employees who have been trained … in the criteria for placing the PRF.”
Veteran-Perspective and Policy Implications
From the veteran’s point of view, PRFs can be both protective and frustrating. Some appreciate that staff are alerted and safety is improved, while others feel the alert leads to quieter referrals, delays in scheduling, or being treated more like a risk than a patient. Advocacy groups argue for transparency, clarification of how the flag affects their care pathway, and stronger mechanisms for appeal or review.
For policymakers, PRFs present an interesting model of “difficult patient” management within a large health system. They raise questions: How many flags are active? What are the review/exit rates? Does being flagged correlate with different health-outcome metrics? Are veterans aware of being flagged and have mechanisms to contest the flag? The 2023 directive begins to set national-level oversight (via the National PRF Advisory Board), but public data remains limited.
Looking Ahead
As VA continues its shift toward integrated care and coordinated risk-management, the PRF system may expand or evolve, potentially integrating predictive analytics, behavioral health markers, or AI‐driven risk flags. Implementation must balance patient rights and privacy with facility safety and workforce protection.
For veterans and caregivers, it’s important to ask: If you’ve been flagged, ask what it means. What protocols will staff use? How does the flag affect your care and rights?
Transparency and review are crucial. On the institutional side, VA will need to deliver consistent criteria, clear review cycles, and strong governance to ensure flags are protected without harming.
In a system built to serve those who have served, the PRF tool represents both promise and challenge: it is a mechanism of safety, yes – but one that demands ethical oversight, clear rules, and respectful treatment of veterans as patients first.
