How to Scan Your Patient Medical Records in 10 Steps

Summary

This 10-step guide outlines a comprehensive process for scanning medical records to ensure accuracy, security, and efficiency. Key steps include documenting the process, selecting a quality control method, naming files based on index fields, and conducting thorough preparation to prevent scanning errors. The guide emphasizes using ANSI standards for quality control, performing scans at 300 dpi for optimal clarity, and verifying files post-scan. By following these steps, healthcare professionals can streamline their record-keeping, minimize errors, and ensure proper documentation for audits, ultimately improving the quality and security of medical record scanning.

Takeaways

• 😀 Documentation is crucial for compliance with CMPA regulations and for clarity during the scanning process.
• 😀 Quality control should be planned in advance to avoid issues like misidentified or missing documents, with ANSI standard Z1.4 as a recommended guideline.
• 😀 Medical records should be named using four index fields, including a unique identifier like last name, first name, or health card number, to streamline the process.
• 😀 Counting pages at the batch and document levels ensures that no pages are missed during scanning.
• 😀 Proper preparation (prep) of documents, including removing staples and ensuring pages are aligned, is essential for smooth and efficient scanning.
• 😀 Scanning resolution should be set to 300 dpi to ensure high-quality scans, especially for documents with small text or illustrations like ECGs.
• 😀 After scanning, records should be named and saved according to the predefined index fields, with proper security measures in place for access.
• 😀 Quality control should continue after scanning to verify accuracy, document reproduction, and correct patient identification.
• 😀 A final verification step ensures that the scanning process is complete, with no missed pages or errors.
• 😀 Proper execution of all steps ensures an efficient, effective, and compliant scanning process for medical records, reducing the risk of errors or mismanagement.

Q & A

Why is documenting the scanning process important?

Documenting the scanning process is essential for compliance with CMIA standards and helps clarify the workflow. It also serves as evidence during audits and ensures consistency across the team.

What is the recommended quality control process for scanning medical records?

The recommended quality control process is ANSI standard Z1.4. This standard helps avoid errors like missed documents, illegible scans, or misidentification of patient records.

How should scanned medical records be named?

Scanned medical records should be named using at least four index fields, such as the patient's last name, first name, date of birth, and a unique health card number.

What is the purpose of using barcodes in the scanning process?

Barcodes placed on separator sheets can automate the naming of scanned records, saving time and ensuring accuracy by linking the documents with specific patient data.

Why is counting pages at the batch level necessary?

Counting pages at the batch level ensures that every document is scanned and accounted for. It helps cross-check the number of paper and digital pages to prevent missing or duplicated pages.

What should be done during the preparation (prep) phase of scanning?

During prep, it's crucial to remove staples, flatten pages, reposition sticky notes, trim edges, and address issues like faded fax pages. This ensures a smooth scanning process with minimal interruptions.

Why is a 300 DPI resolution recommended for scanning medical records?

A resolution of 300 DPI is recommended because it ensures the scanned images are clear and legible, which is particularly important for medical documents such as ECGs or growth charts that require high visual quality.

What role does quality control play after scanning?

Quality control after scanning ensures that the scanned documents meet the required standards. It involves verifying the image quality, matching page counts, and ensuring that the records are correctly attributed to the right patient.

What is the purpose of the final count and verification step?

The final count and verification step ensures that all documents have been scanned properly, confirming the accuracy and completeness of the scanned records before concluding the project.

How does SRS support organizations with medical record scanning?

SRS offers expert services for medical record scanning and storage, ensuring that projects are completed correctly the first time. They provide guidance and additional support to ensure the scanning process is efficient and compliant.