OLC Clarifies Surveyor Access to Electronic Health Records

In response to questions related to surveyor access to Electronic Health Records (EHRs) posed during the Nursing Facility Advisory Committee meeting held at the Office of Licensure and Certification (OLC), providers were reminded of things to consider and their responsibilities during the survey process.  As increased numbers of providers embrace the efficiencies of an EHR, OLC has requested that the following information be shared with providers.

A provider must grant access to the EHR when requested by the surveyor.  The surveyors are considered “covered entities” and, therefore, should not be required to provide personal information to gain access to the EHR.  Each facility should define by policy what constitutes a medical record, and the surveyor should have access to the complete medical record as defined by the facility's policy.  A key staff member should also be designated to provide a quick tutorial to the EHR to each surveyor and remain available should there be any questions.

It is recommended that each surveyor be provided with a computer or access to a computer terminal at the care locations.  In addition, facility staff should instruct the surveying team how to print the records the team needs in paper form.  

It is important for the provider to assure that attention is given to each of these areas when making the decision to move to an EHR.  Waiting until a survey to consider these items may present problems for the provider that may be viewed as impeding the survey process.

A memorandum to State Survey Agency Directors dated August 14, 2009, “Surveying Facilities That Use Electronic Health Records” states, “During the entrance conference, surveyors will verify with the facility the process they will follow in order to have unrestricted access to the medical record.  Impeding the survey process by unnecessarily delaying or restricting access to the medical records may lead to termination from Medicare participation.”  To read the entire Survey and Certification Memo (S&C-09-53) please click here.