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.

Regarding 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.

Regarding 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.

  
Last updated on August 01, 2020
Manual: Ambulatory
Chapter: Leadership LD

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