to main content Records and Documentation - Format/Availability | Behavioral Health | Leadership LD | The Joint Commission
Records and Documentation - Format/Availability

What form of documentation is acceptable by The Joint Commission, electronic or paper? How quickly must documentation be accessible during a survey?

Any examples are for illustrative purposes only.

The Joint Commission surveyors will accept evidence of standards compliance in either a paper format or an electronic format. In either case, the documentation must be organized or accessible in such a way as to allow for timely review. For example, electronic medical records,  environment of care records, emergency management and life safety documentation can be completed  by reviewing a computer screen or wall projection.

Please note:
  • A person from the organization must be available and have knowledge on how to efficiently navigate the electronic format.
  • If the documents are not in English then a translator should be available to interpret.
 The timeliness of accessibility to required documentation is an evaluative determination. The surveyor will work collaboratively with your organizations to establish a time frame to submit requested documents.  If the organization demonstrates a consistent pattern where requested documents are not readily available, then a Leadership finding (LD.04.01.05) may be made in addition to the requirement for improvement (RFI) for the missing documentation.

The Accreditation Survey Activity Guide (SAG) for Health Care Organizations, available to organizations via their secure extranet site or our website, includes a list of the documents required to be available to the survey team. Organizations may find it helpful to conduct 'mock surveys' that include evaluating timely access and availability of these documents.

Medical Records
There is no prescribed, required or recommended format for medical records. At the time of survey, medical records are evaluated for content, based on the applicable accreditation Elements of Performance (EP), not format. Organizations operating in a hybrid environment (both paper and electronic) or are in the process of migrating to an Electronic Medical Record (EMR) platform should have a 'super-user' available to staff during the survey to assist in navigating the record to locate information requested by the surveyor.

Clarifications and Lack of Required Documentation During Survey
Findings resulting from  'lack of required documentation at the time of survey' are not eligible for the clarification process. When an organization does not have required documentation available at the time of survey, the organization can expect that the surveyor will give the organization a reasonable amount of time to produce missing documents.  Following the survey, the organization will need to provide Evidence of Standards Compliance (ESC) that the required documentation has been addressed through corrective actions.

Manual: Behavioral Health
Chapter: Leadership LD
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on October 19, 2021
Was this response helpful?

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form

Get Extra Help with Books and E-books

Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.

Stay Informed with Online Education

Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.

Reach Your Safety Goals with eProducts

Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.

Can't Find What You're Looking For?

If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG).

Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. The Joint Commission no longer answers questions submitted by students or vendors. Thank you for your understanding.