AGING AND DISABILITY SERVICES ADMINISTRATION

2009 AFH "Dear Provider" Letters

July 31, 2009

ADSA:  AFH #2009-014
Electronic Health Records aka Computerized Medical Records

Dear Adult Family Home Provider:

We have recently become aware that some adult family homes are using or intending to use electronic health records (EHR) systems.  Homes that choose to use this type of recordkeeping system must continue to follow all regulations.  This includes providing the department ready access to all current records and to closed resident paper records retained before the home began using the electronic health records system.

If your home uses an electronic health record system, you should plan on how you will provide ready access to authorized department staff, such as licensors and complaint investigators by one of the following ways:

• 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 electronic health records.  Providing this information should not be time consuming or complicated.

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

• The adult family home must ensure that the records are available for review to department staff when requested. (WAC 388-76-10315).  It is your responsibility to determine in what manner you provide the department access to records;
• The department may make an unannounced inspection at any time.  Inspections include a review of resident records (RCW 70.128.070 and RCW 70.128.090);
• The adult family home must ensure that the resident records contain enough information so the home can provide the needed care and services to the resident.  The adult family home must also ensure staff has access to parts of each resident’s record needed to provide care and services.  Please remember you are responsible to provide care and services to residents even in the event the computer is not working or the electricity is out. (WAC 388-76-10315); and
• Maintain resident records and preserve their confidentiality in accordance with applicable state and federal statutes and rules, including chapters 70.02 and 70.129 RCW.

Here are some concepts the adult family home needs to consider when setting up an electronic health record system:

• The computer program controls what sections/areas individuals can access or enter data, based on the individual’s personal identifier.
• Develop a written policy, which includes the attestation policy for use of electronic signatures.
• Each person responsible for an attestation must have an individual identifier.
• The adult family home must have a back-up system to provide the necessary resident care and services if the computer is not working.
• The computer must have built-in safeguards to minimize the possibility of fraud or inadvertent record alteration.
• 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.

If you intend to implement an electronic health record system in the future, please inform your RCS Field Manager so that he or she knows ahead of time your record keeping system and can plan accordingly.  Remember that you must be able to give authorized department staff ready access to any records they need, at any time.

Sincerely,

Joyce Pashley Stockwell, Director
Residential Care Services