Health Information Technologies and Processes

Scanning Paper Records into an EHR

  • 1.  Scanning Paper Records into an EHR

    Posted 10-22-2020 13:31

    Is anyone willing to share with me the policy, or process, you follow when physicians retire, or leave your organization, and have paper records and an EHR?  Particularly, in regard to the paper records.   

    • Upon leaving, or retirement, do you allow the office to back scan any part of the paper record, prior to going electronic, into your EHR?
    • If so, do you have a policy as to what they are allowed to scan, how far back can they go, where it is scanned, and how it is labeled within your EHR?
    • What is your facility's retention period?

    We currently do not encourage our physicians to back scan documents into our EHR as we feel it should not be used as a repository; however, I would like to get an idea if this is the industry norm. 

    Thank you for your help. 



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    Misty Hamilton, MBA, RHIT
    Professor/Director HIMT

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  • 2.  RE: Scanning Paper Records into an EHR

    Posted 10-23-2020 08:28
    I don't know if this will help you as I am a little confused by your question, but I will try to explain what we have done recently. We had one non-hospital employed physician move from the area. He approached us about housing his records upon the close of his practice. He did have an EMR so he was able to work with his vendor to get a download of his MPI and all of his patient records in PDF format. It was given to him, and passed on to us, as an external hard drive. Our IT team backed it up to one of our protected shared drives, but the external drive lives in HIM so they can handle any requests that may come from his former patients. We will maintain the data until it's time to dispose of it per our state law. On the flip side, we have had a few self-employed physicians become employed by the hospital. It has been written in the contracts that we will assume care of their records as well, they are mostly all paper (but one had an EMR so we followed the first process that I outlined.) We did not "back scan" anything in bulk really. The doctor and the team working on the transition will review the upcoming schedules combined with the records and basically sort them into active and inactive records. We will store the inactive paper records off site, but can retrieve them if necessary. Thankfully there has been room for the remaining paper records in the practice so they are reviewed/purged as patients come for their visits. The team will perform "chart prep" on patients who have upcoming visits. (It also gives any new employees much needed practice navigating the EMR). They enter the medications, allergies and PFSH. The physician will reference the paper chart for the patient's visit and identify anything he feels is important enough to be scanned for quick and easy reference in the future and then the record will be transitioned to inactive storage.

    I'm sorry this is so long, I hope it helps to give you some ideas that may work for your scenario.

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    Kathryn Wood, RHIA
    Assist Dir of Information Systems/Privacy Officer
    War Memorial Hospital
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  • 3.  RE: Scanning Paper Records into an EHR

    Posted 10-26-2020 08:08
    Thanks Kathryn, That does help.  We had a physician who joined our physician group in 2017, and began using our EHR at that time.  She is now retiring and had her employees scan all of her progress notes, for every patient she has ever had, into the EHR.  Our typical practice is similar to yours above, HIM would release from the EHR and store her paper records.  We were unaware that she had them scanning the documents until it was completed.  I wanted to find out if we were following the industry norm regarding "back scanning" of paper records.

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    Misty Hamilton, MBA, RHIT
    Associate Professor/Director HIMT
    Zane State College
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  • 4.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    Hi Kathryn, 

    I am interested in any insight you might have for workflow suggestions.  It seems you went through a similar scenario that I am experiencing.

    A local (non-staff) provider will be retiring and I will take ownership of the practice's records.  The practice provided notice to their patients with a phone number to call should they be interested in assuming care with one of our on-staff providers.  The retiring provider had all paper records.  I am concerned with back scanning, as it can create confusion with where to locate the records and create duplicate information and lower the integrity of the record.  However, the patient's are spreading out throughout various practices within our entity who are located off-site.  The only feasible way I can determine to get the record to the provider's who are continuing care is to scan them to our EMR, possibly under external records.  Thoughts? 



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    Ashley F.
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  • 5.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    Hi Ashley,

    Our situation is very much the same. We took custody of the paper records, but did not scan them. When one of our providers wants the patient's records, we have them go through the paper record and flag the documents they want (or more likely they tell the nurse that has to jot it all down.) They return the record and we can the pieces that they would like into the "Other Facility" record documents for future review. The paper chart goes back to paper storage to await it's destruction time. I hope that helps.

    Katie

     

    Katie Wood, RHIA

    Assistant Director of Information Systems/Privacy Officer

    War Memorial Hospital

    500 Osborn Blvd

    Sault Ste. Marie, MI  47983

    p: 906-635-4663   khwood@wmhos.org

     






  • 6.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    Thank you Kathryn for your response.  I think some of the difficulty for us is that the ambulatory providers who will be continuing the patient care are not located on site where the records will be stored/maintained.  It would be difficult to provide them with the paper record that will be maintained at our acute hospital. However, the are on the same EMR as us.



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    Ashley F.
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  • 7.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    When we've taken over practices like that, we don't back-scan automatically.  If/when that patient shows up in the future, we would pull it and scan it then, but not just scan everything, 



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    Seth Katz
    Vice President of Him and Revenue Cycle
    Truman Medical Center
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  • 8.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    Do you separate the record by scanning into separate document ID's, for example Office Notes, Consult Notes, Procedure, etc., or do you scan the complete record to one single document ID? 

    Does this cause any confusion whenever retention is met?  The paper record would be destroyed for a particular year, some may be scanned in while others are likely not?



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    Ashley F.
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  • 9.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    We don't break up the old chart like that.  It gets scanned together.  We found the time necessary to break it down wasn't worth the value of the data it was bringing to the clinicians by having it broken up in our EMR.

    As for retention, once something is scanned, our Legal and Compliance departments deem the paper the copy, and what's in our EMR the original.  So once we scan that old chart, our policy is to keep scanned documents 60 days post scanning for audits and then shred it, 



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    Seth Katz
    Vice President of Him and Revenue Cycle
    Truman Medical Center
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  • 10.  RE: Scanning Paper Records into an EHR

    Posted 27 days ago

    Thanks Seth!



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    Ashley F.
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  • 11.  RE: Scanning Paper Records into an EHR

    Posted 26 days ago

    We do the same thing as Seth – we don't back scan anything.

     

     

    Susan Hatem, MSM, RHIA, CRCR

    Health Information Management Director

    image007.png@01D492C1.5078E270

    Medical Center Boulevard

    Winston Salem, NC  27157

    P: 336-716-3236  F:  336-716-5386

    shatem@wakehealth.edu