Surveying Facilities that use Electronic Health Records (EHR)

On August 14, 2009, a Survey and Certification Memo (Ref: S&C-09-53) was released in regards to the Electronic Health Records access to records by surveyors. The provider must provide access to any medical record, including access to EHRs, when requested by the surveyor. During the entrance conference, the survey team will clarify the process that will be followed to have unrestricted access to the medical record. It is the facility's responsibility to provide direction on the use of the electronic system or to designate an individual to access the system in response to questions or to assist the survey team. A delay in the acquisition of the medical record is unacceptable and may delay the survey process.

Surveyors need to have access to facility records regardless if the records are paper or electronic record systems. Surveyors will verify the process to follow for access to the medical record. Delaying the access or impeding the survey process, would warrant contact by the State Agency to CMS which may lead to termination from Medicare participation.