Texas Medical Liability Trust

Risk Management Practice Review Questionnaire

ELECTRONIC MEDICAL RECORD

The TMLT questionnaire is to be completed prior to the representative’s visit.

Please have it available at the scheduled risk management site visit.
Physician(s) name: Rudy Alvarez PR date: 02/10/18
Group name: RGV Pathology Consultants, P.A. Office location: 301 W. Expressway 83, McAllen TX
78503
Number of physicians: 3 Policy number(s):      

CRITERIA COMMENTS
A. SECURITY
1. Have you conducted a Risk Analysis/ Assessment      
as required by the HIPAA Security Rule? Yes No
2. Does the system have security controls allowing      
specific levels of access to employees and is this
reflected in your policy and procedure manual? Yes No
3. Is your system in compliance with all HIPAA Security      
rules? Yes No
4. Do you have a written Business Associate      
Agreement with all third parties (software vendor,
tech support, offsite data storage facility, etc.)
regarding the confidential nature of the health
information? Yes No
5. Is there a written protocol on system security? Yes No      
6. Are firewalls utilized to protect the records from      
unauthorized access? Yes No
7. Do you have anti-virus software on all devices or      
other security breach protection? Yes No
8. Is encryption used when protected health      
information is transmitted and at rest? Yes No
9. Are employees prohibited from loading unauthorized      
software onto the system? Yes No
B. GENERAL
1. What electronic medical record system do you use?
Software name:      Cerner        
What date did it become fully operational? 04/2013
Does your system utilize?
Desktops
Portable Devices (Laptops, etc.)
Tablets
Other (Please Describe)
2. Does your system support a totally paperless      
operation? Yes No
If not, what part of the record remains in hard copy?      
Please explain in the comments section to the right.
3. Have you printed a complete medical record from      
your system? Yes No
Does it include labs, phone call documentation, etc? Yes No      

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 CRITERIA COMMENTS
4. Does the system automatically date stamp entries      
made in the record? Yes No
Are lab, diagnostic tests and consultant reports
integrated into the system? Explain how in the
comments section to the right. Yes No
5. Does the system document when labs, diagnostic      
and consultant reports were reviewed by the
physician? Yes No
6. Does the record identify each person making      
entries? Yes No
Is the identity of the person seen on the printed
record? Yes No
Are scribes utilized by anyone in the practice? Yes No
7. Does the system offer a single screen summary of      
the problem list, allergies, medications and health
education/prevention prompts? Yes No
8. Are all communications (including but not limited to Yes No      
phone calls, emails, texts, and conversations
outside of the office) regarding patient care entered
into the medical record?

9. Does the system interface with:      

Laboratories
Radiology providers
Hospitals
Health Information Exchange (HIE)
10. Does the system offer appointment scheduling? Yes No      

What reporting features does your system offer?

List of pending lab and consult results
List of unsigned/open records
List patients on a specific drug
List patients with a specific condition
Graphing vitals, lab values, etc. over time
11. Is training and support received from the vendor? Yes No
Does the contract with the vendor specify that in the
event of a dispute they will not prevent you from
using the system? Yes No
C. DISASTER PLANNING
1. How often is patient health information backed up?            
Is a copy stored in a secure off site location? Yes No
Have you tested the integrity of the backup,
ensuring it will completely restore the data in the
event of a system failure?
What is the oldest backup data you can restore?      
D. ACCESS CONTROLS
1. Who may access the system from a remote Physicians
location? Please list in comments section to the
right.
2. Is there a written policy that prohibits the sharing of      
passwords, access codes, key cards, etc.? Yes No
3. Are passwords changed every 90 days? Yes No      
4. If an employee is terminated, are the passwords      
and access codes changed immediately? Yes No

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 CRITERIA COMMENTS
E. ENCOUNTER-PROGRESS NOTES
1. Are details of the encounter (chief complaint, vitals, n/a
assessment, plan, etc.) entered:
during the patient visit
immediately after the visit
Other (Please explain in comment section)
2. Are there templates for the creation of encounter-      
progress notes? Yes No
If templates are used, are all populated fields
modified at each visit to reflect accurate information
for the patient? Yes No
3. Can you modify the system templates, drop-down      
lists, etc. to meet your needs? Yes No
Do your templates conform to Texas Medical Board
guidelines (Chapter 165 Medical Records), including
the requirement that all non-biographical populated
fields contain accurate data? Yes No
F. DOCUMENTATION
1. Is there a policy in place for making an addendum      
or an amendment to the electronic notation? Yes No
Is the original entry left in the record? Yes No
Is it obvious a correction was made? Yes No
Does the system record who made the correction
and when? Yes No

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referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including
expert testimony. They are intended as resources to be selectively used and always adapted – with the advice of the organization’s
attorney – to meet state, local, individual organizations and department needs or requirements. They are distributed with the
understanding that neither Texas Medical Liability Trust, nor Texas Medical Insurance Company, nor Lone Star Alliance, Inc., a Risk
Retention Group, is engaged in rendering legal services.

Electronic Medical Record Questionnaire

Revised 12-04-14 Page 3 of 3