Documentation Management in Support of the Electronic Health Record

C. Matheson, RHIA, CCS Outsourcing Leave a Comment

Electronic Health Records (EHRs) continue to change the landscape of healthcare.  Although the technology and workflow of electronic documentation seems to make paper documents obsolete, a hybrid medical record exists in many healthcare settings.  Organizations need to determine which paper documents to include with the EHR, access to that documentation and when to include that information when releasing protected health information (PHI). Document management impacts patient care as well as the revenue cycle. The scanning of documents presents multiple options for the Health Information and Clinical teams.

WHO should scan? 

When it comes to staffing the scanning/imaging function, the right skill sets are required. If this is the sole role, the function can be monotonous.  The individual requires attention to detail, technology savvy to deal with the computer and scanning equipment, ability to page through stacks of paper, organize documents and be motivated to achieve production goals.  If the role is combined with other functions such as patient registration, medical assistant and/or scheduler, then the priorities of the position may be multifaceted.  Who is scanning and job responsibilities will impact metrics and establishing productivity benchmarks.

WHAT to scan?

The foundation of defining what to scan is based upon the definition of the legal medical record. The types of documents for scanning include patient advance directive/healthcare proxy, legal guardianship documents; registration documents such as consent for treatment, consent for procedures; Medicare notices; patient communication documents that require a patient signature such as discharge instructions; medical records generated by other providers and healthcare organizations.  Additional considerations include what PHI should be released when requested by the patient, insurance company, attorney, etc.  Is the disclosure management system set up to handle the release of electronic and scanned documents efficiently?

When to scan?

When to scan considerations include pre-service/pre-appointment, concurrent with the appointment/ point of care and post service/post discharge.  One strategy does not fit all and dependent upon the decision, the considerations outlined above under staffing may impact when to scan the documents.  If the setting is surgical/procedural based, scanning pre-service/appointment can streamline managing the documents one time since once scanned, clinical staff can access the clinical information concurrently.  Scanning concurrent with an office visit or point of care presents considerations such as should the paper documents remain available during the patient treatment period?  If so, how are documents identified as “scanned” and how do clinical staff know not to add documentation to a scanned document?  If scanning occurs post service/post discharge, is staffing sufficient to scan the documents timely in order to have minimal impact on the coding operation and billing process?

WHERE to scan?

In determining where to scan documents, consideration of equipment needs must be considered.  If scanning will be conducted in clinical areas, is the scanning equipment located in the clinical area or mobile such as a computer/scanner on wheels?  What is the impact on productivity based upon the equipment utilized? Should documents be removed from the clinical area and scanned in another location and is this feasible for concurrent scanning?

Regardless of the who, what, when or where of document management, staff education and training are the basis for a strong program.  The quality control and quality monitoring to ensure accuracy is also key to ensuring PHI is indexed to the correct patient and with quality images.  A systematic approach with documented workflow processes, productivity metrics and quality standards will enhance the EHR in support of the revenue cycle and patient care.

Laureen A. Rimmer, RHIA, CPHQ, CHC

Vice President, Department Management










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