AGING AND DISABILITY SERVICES ADMINISTRATION

2007 BH "Dear Provider" Letters

October 23, 2007

ADSA: BH #2007-016
Computerized Medical Records

Dear Boarding Home Administrator:

With advancements in computer software, some boarding homes (BHs) are implementing or intending to implement computerized medical record systems. Homes that choose to use this type of recordkeeping system must still follow all regulations. This includes providing the department ready access to all current records and to closed resident paper records retained before the home implemented the computerized medical records system.

If your home utilizes a computerized medical record system, you should plan on how you will provide ready access to authorized department staff, such as licensors and complaint investigators 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 boarding home must:

• Allow authorized representatives of the department and other authorized regulatory agencies access to any resident record (WAC 388-78A-2400). The department may at anytime make an unannounced inspection of a licensed home and every inspection shall focus primarily on actual or potential resident outcomes, and may include an inspection of every part of the premises and an examination of all records (RCW 18.20.110). It is your responsibility to determine in what manner to provide access to records to boarding home licensors.
• Maintain a systematic and secure method of identifying and filing resident records for easy access (WAC 388-78A-2400); 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 is an example of guidelines on how a boarding home 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 computers 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