AGING AND DISABILITY SERVICES ADMINISTRATION

2005 NH "Dear Administrator " Letters

February 21, 2005

ADSA: NH #2005-005
CLARIFICATION—ELECTRONIC SIGNATURE GUIDANCE

Dear Nursing Facility/Home Administrator:

The Centers for Medicare and Medicaid Services (CMS) recently issued a State Operations clarification letter to all state agencies related to electronic signature guidance. The original guidance on electronic signatures was issued on September 9, 2004.

Long term care providers, that is Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs), may implement use of electronic signatures for their clinical record documentation, including the MDS, whether or not the clinical record is entirely electronic, if:

1. It is permitted by state and local law, and
2. Authorized by the long-term care facility’s policy.

The policies must address the following issues:

1. Identify which person(s) in the facility are authorized to sign electronically;
2. Identify safeguards put in place to prevent unauthorized use of the electronic signature; and
3. Maintain privacy and confidentiality of resident health record information with the use of the electronic signatures.

While Washington State does not have any state laws that prohibit the use of electronic signatures in the clinical record, including the MDS, Washington Administrative Code (WAC) 388-97-085 (5)(b) does require that a copy of the completed RAI be placed in each resident’s clinical record unless all charting is computerized.

Thus, a long-term care facility may implement electronic signatures in the clinical record, including the MDS, but they must also have a completed hard copy of the RAI in the resident’s clinical record, unless all of their charting is electronic.

If you have any questions or need further information, please contact Marjorie Ray, RN, Washington State RAI Coordinator, at (360) 725-2487 or e-mail rayma@dshs.wa.gov

Sincerely,

Joyce Pashley Stockwell, Acting Director
Residential Care Services