Electronic Health Records

Electronic Health Records A. The Division of Medicaid recognizes an electronic health record (EHR) as an electronic version of a beneficiary’s medical history and key administrative clinical data relevant to a beneficiary under the care of a particular provider, that is maintained by a provider over time, and may include, but is not limited to: 1. Demographics, 2. Progress notes, 3. Problems, 4. Medications, 5. Vital signs, 6. Past medical history, 7. Immunizations, 8. Laboratory data, and 9. Imaging data. B. A provider may use an electronic signature (e-signature) in an EHR. E-signatures in EHR must: 1. Meet certified electronic health record technology (CEHRT) criteria according to the National Institute of Standards and Technology (NIST) and the Office of the National Coordinator for Health Information Technology (ONC) standards, 2. Be in compliance with both Uniform Electronic Transactions Act (UETA) and Electronic Signatures in Global and National Commerce Act (ESIGN Act) standards, and 3. Maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) in regards to the access, transfer, storage and signing of EHRs. 4. Comply with Division of Medicaid requirements regarding e-signatures. [Refer to Miss. Admin. Code Part 200, Rule 1.10.] C. A beneficiary may use an e-signature in an EHR. The beneficiary must: 1. Consent to the use of an electronic signature when completing necessary forms, including, but not limited to, the consent for treatment. 2. Be given the option to use an electronic or handwritten signature. 3. Be furnished an electronic or printed copies of all documents electronically signed. 4. Comply with Division of Medicaid requirements regarding e-signatures. [Refer to Miss. Admin. Code Part 200, Rule 1.10.]