To help avoid issues that can reduce the credibility of scanned records you should consider developing an office policy on scanning.

Posted in Malpractice Insurance on Tuesday, September 20, 2016

Scan paper documents into your electronic medical records (EMR) – it sounds easy enough, what could possibly go wrong?

Whether you are scanning a single outside report, or making the transition from paper records to EMR, the task seems fairly simple. However, the need for scanning quality control does exist and it may be more important than you have realized. 

Consider the following real-life scenario. Office clerical staff scanned in EKG reports to their EMR system. Later, as the providers opened patient records to compare current to previous EKG reports, they realized that the patient’s identifying information from the previously scanned reports had not been captured from the paper record. As a result, this reduced the credibility that the previous EKG information was indeed from that particular patient. 

How can you improve scanning quality control at your practice?

To help reduce the chance of scanning issues, you should consider developing an office policy on scanning that includes procedures such as:

• Visual inspection of each scanned document to ensure that the image is complete and that the entire document has been captured.
  • The scanned image must be clear, easily read and usable.
  • The scan should show the entire document in good quality and should not be skewed.
• If a good, clear scan is not obtainable, the record should be noted as being the “best possible scan.”
• Comparing scanned records with the original paper documents to confirm accuracy.
• Validating the original number of paper documents compared to the number of scanned records to ensure every document was scanned. In this process you should:
  • Check for two sided pages.
  • Note blank pages as “Intentionally left blank.”
• Quality controls in the manner of a periodic audit by the IT department or practice manager. This should be done when scanning projects are underway to check for critical errors such as:
  • Documents scanned to the wrong chart.
  • Documents that are not complete/clear/readable.
  • Documents missing patient identifiers.
  • Documents missing pages with no explanation or identification of what was excluded.

For more information on scanning and quality control, the American College of Medical Practice Executives has published a case study on Scanning Medical Records to an EMR that is now available online.