Electronic Health Records in Nursing Facilities

DADS issued Provider Letter No. 17-20 regarding Electronic Health Records in nursing facilities. The provider letter stated that the NF may use the system of medical records that best suits their needs whether it is paper or an electronic system. Regardless of the system, NFs must allow Texas Department of Aging and Disability Services (DADS) surveyors complete access to their records.

In the corresponding CMS Survey and Certification letter 09-53, the following are responsibilities of the facility regarding surveyor access to EHRs:

  • provide surveyors a tutorial on how to use its particular EHR system;
  • designate one individual who will, when requested by a surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing electronic information in a timely fashion;
  • provide a terminal or terminals where the surveyors may access records; note: having more than one terminal available helps the survey process continue to move forward as more than one surveyor at a time is able to complete the task of record review;
  • provide access to records in a read only format whenever possible to avoid inadvertent changes to the record; and
  • either provide direct print capability to surveyors or make available a printout of any record or part of a record upon request in a timely manner that does not impede the survey process.

For access to the letters go to: https://hhs.texas.gov/sites/hhs/files//documents/doing-business-with-hhs/provider-portal/letters/2017/letters/pl2017-20.pdf