AGING AND DISABILITY SERVICES ADMINISTRATION

2007 NH "Dear Administrator" Letters

October 23, 2007

ADSA: NH #2007-028
Computerized Medical Records

Dear Nursing Facility/Home Administrator:

It has been brought to my attention that more nursing facilities are implementing or intending to implement a computerized medical record system. Facilities that choose to use this type of recordkeeping system must still follow all federal and state regulations. This includes providing the department ready access to all current records and to closed resident paper records retained before the facility implemented the computerized medical records system.

If your facility utilizes a computerized medical record system, you should plan on how you will provide ready access to authorized department staff, such as surveyors, complaint investigators and quality assurance nurses by either:

• Designating a staff person to assist the authorized department representatives in accessing the records when needed; or
• Providing department staff, at the beginning of the visit, with the information necessary to easily access and print your computerized records. The provision of this information should not be time consuming or complicated.

Please remember the following laws and rules related to resident records.

The facility must:

• Make all records available to authorized representatives of the department for review and duplication as necessary. Any authorized employee of the department may enter and inspect any nursing home, including, but not limited to, interviewing residents and reviewing records, at any time. (RCW 18.51.210, WAC 388-97-180) It is your responsibility to determine in what manner to provide access to records to nursing home surveyors, complaint investigators or quality assurance nurses.
• Maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized. (F-tag 514, 42CFR 483.75 and WAC 388-97-180)
• Safeguard clinical record information against alteration, loss, destruction and unauthorized use and keep confidential information contained in the resident’s records (F-tag 515 and 516, 42CFR 483.75, WAC 388-97-180)
• Not change medical records once it has been recorded (1996 Health Insurance Portability and Accountability Act and Manor Care-Bethlehem case)

Per interpretive guidelines at 42CFR 483.75, the following are examples of how a facility may choose to set up a computerized record system:

• There is a written policy, which includes the attestation policy for use of electronic signatures.
• The computer has built-in safeguards to minimize the possibility of fraud or inadvertent record alteration.
• Each person responsible for an attestation has an individual identifier.
• The date and time is recorded from the computer’s internal clock at the time of the entry.
• An entry is not changed after it has been recorded.
• The computer program controls what sections/areas any individual can access or enter data, based on the individual’s personal identifier.

If you intend to implement a computerized medical record system in the future, please inform your field manager so that they know ahead of time your record keeping system and can plan accordingly. Remember that you must allow authorized department staff ready access to any records they need.

Sincerely,

Joyce Pashley Stockwell, Director
Residential Care Services