Scanning Information Into The Electronic Health Record (EHR)
It’s a fact. Without HIM best practices for scanning information into the electronic health record (EHR), organizations run the risk of poor quality images that are unreadable, unreliable, and that could pose significant risk to patients.
It isn’t difficult to imagine a scenario in which a physician can’t make a critical medical decision because he or she can’t see the image clearly. What if the physician makes a decision based on information that shouldn’t have been scanned into that particular EHR (i.e., information that belongs to another patient)? Poor quality images also pose risk related to HIPAA. What if the scanned information is subsequently released to a patient who shouldn’t have access?
Many organizations are faced with an insurmountable volume of information stored in paper records that they must somehow either incorporate into the EHR or retain in some way (e.g., at an offsite storage location). Some organizations decide to do both—that is, digitize the information and then retain paper records pursuant state and federal law. Either way, the process of scanning information into the EHR requires an impeccable attention to detail as well as clear policies and procedures to ensure compliance.
Why HIM’s Voice Is Vital
When setting parameters for scanning, HIM leadership must help answer these five important questions:
- Will the organization scan from a designated date forward, or will it back-scan paper records?
- If back-scanning, how far back in time will HIM go when scanning? It’s important to be at the decision-making table as much as possible to voice concerns and raise questions. For example, how might back-scanning affect current-day workflow? Will additional FTEs be necessary? Is additional technology necessary? Does the current technology support an efficient workflow?
- Do current staff members possess the skill sets necessary to prep, scan, index, and perform quality control? Is additional training required? It may be less expensive to outsource these functions. If retaining the labor in-house, determine whether each step will be a separate activity performed by a different individual.
- How will scanned documents be stored? Will they be part of the EHR or stored in a separate file online?
- What policies and procedures must the organization create to detail scanning procedures for each type of scenario that an employee (or outsource staff member) might encounter? For example, does the process differ when scanning external vs. internal documents? External documents could include documents from another provider as well as from the patient him or herself. Will any of the scanning take place concurrently (i.e., while the patient is still admitted)?
HIM Best Practices For Scanning
Setting forth best practices helps employees (or outsource staff members) ensure compliance and consistency. Consider the following four best practice steps that every scanning process should include:
Step 1: Prep the record. This step not only ensures that the record passes smoothly through the scanner, but it also helps enhance data integrity. Consider the following:
- Remove all staples as well as chart dividers and post-it notes. Tape down any loose documents. Smooth the documents so they don’t include any folds or wrinkles. Ensure that no documents are stuck together. Use caution when separating or tearing documents apart.
- Ensure that all documents follow a clear chronological/sequential order. This is particularly true for flow sheets.
- Ensure that all documents belong in the medical record. To do so, verify whether the patient identifier is correct and consistent on every page.
Step 2: Index the record. (This could also be part of prepping the record) During this step, each document is assigned a value at the point of scanning. Consider the following:
- Index documents according to their specific type (e.g., history and physical, consultation, etc.).
- Validate the patient name on all documents.
- Confirm that the identity of the patient listed in the paper documents corresponds with the identity of the patient in the EHR.
Step 3: Scan the record. This phase includes the actual scanning of the documents and requires strict attention to detail. Consider the following:
- Fan through the documents. Shake the stack of documents to ensure that no staples are stuck between the pages.
- Begin the scanning process. Keep your eyes on the screen to monitor the quality of the scanned imagine.
- If a line appears on the scanned image, stop scanning and clean the glass of the scanner.
- Document your initials and the date on the cover sheet.
Step 4: QA the record. This step provides an opportunity to catch errors and improve processes going forward. Consider the following:
- Task each employee with QAing another employee’s indexed batch.
- During the QA process, verify the patient name, medical record number, and date of service. Ensure that this information is consistent on all remaining documents by quickly glancing at every thumbnail page.
- Re-index any documents, as needed.
What are your organization’s scanning best practices? What are your biggest challenges? To learn more about MRA’s scanning support services, visit our Scanning Support section.