Form 1 EHR Readiness Checklist

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Electronic Heath Records (EHR)

FOR HRSA USE ONLY

Application Tracking Number

Grant Number

Electronic Health Records (EHR)

1. Does your health center use ELECTRONIC HEALTH RECORDS (not including billing records)?

[_] Yes, all electronic

[_] Yes, part paper and part electronic

[_] No or Don’t know

2. Is the EHR system certified by the U.S. Department of Health and Human Resources?

[_] Yes [_] No [_] N/A

3. Which of your clinical programs use an electronic system? Of the clinical programs with an electronic system, indicate each program that is integrated within your health center’s EHR.

Clinical Program	Electronic System? (Check if system present)	Integrated into EHR? (Check if integrated into EHR)
Medical	[_]	[_]
Oral/Dental	[_]	[_]
Mental health and Substance Abuse	[_]	[_]
Pharmacy	[_]	[_]
ePrescribing	[_]	[_]
Lab	[_]	[_]
X-Ray	[_]	[_]
Other:	[_]	[_]
Other:	[_]	[_]
Other:	[_]	[_]

4. Are there any plans for installing a new EHR system or replacing the current system?

[_] Install a new EHR within 12 months

[_] Install a new EHR within 13-16 months

[_] Not install an EHR

[_] Unknown