Scanning and Storing Electronic Documents in the Patient Record

Subject: Scanning and Storing Electronic Documents in the Patient Record
Effective Date: September 2016

Purpose

To define the procedures and requirements for correctly scanning hardcopy documents into the patient health record in axiUm.

Creating an electronic record retention system for the patient health record improves operating efficiencies, reduces waste, and minimalizes physical storage space.

General Policy

All School of Dentistry clinics and departments are no longer required to archive paper copies of documents scanned into the patient health record in axiUm. Scans produced following the UW Scanning Requirements outlined in this policy can legally take the place of paper records. Once properly scanned, paper records can then be destroyed.

Scanning or imaging is the process by which paper documents are copied and saved as digital images.  These digital images or electronic records are saved as PDF (Portable Document Format) files only in axiUm. A list of Records Applicable for Electronic Scanning is found in Appendix A.

Scanning paper records does not automatically authorize the destruction of the source documents from which the scanned images have been created.  When it is not possible to create a readable scanned image, the original paper document must be kept and UW records retention policies must be adhered to.

Implementation

I. Procedures

A. Technical Scanning Requirements

The requirements which follow are based on the UW Scanning Requirements.  These requirements must be fully met to justify the use of scanned images as replacements for the original paper records.

1.Formats and Scanning Densities

Black and white, gray, and color paper records can be scanned.  Any kind of record can be scanned including color text documents, photographs, and maps, plans, and engineering drawings.

  • Scanners must be set at a minimum of 300 dpi (dots per inch)
  • Scanned records must be saved as PDF only

2. Quality Control

 Like all electronic records, scanned files must be accessible and readable for their full retention period.  This includes finding the file, opening the file, and reading the file regardless of the software used in its creation.

Scanned document images must be inspected visually to ensure they are complete, clear, and easily read.

  • Scanned records must be compared to the original paper document to ensure accuracy
  • The number of original paper documents must be compared to the number of scanned records to ensure that every document was scanned

3. Image Enhancement

 There are times where there is a problem with the final scanned image that makes it difficult to read and less than usable.  If the scanned document is to replace the original paper record, these common problems must be corrected:

  • Speckles or spots on the scanned image
    • Clean the glass on the scanner and rescan the paper
  • Skewed images that are not properly aligned
    • Rescan the paper so that the image appears straight
    • All portrait orientation pages should be rotated to read from left to right
    • All landscape orientation pages should be rotated with the top of the page facing the left
  • If only part of the document is captured by the scanner
    • Rescan the paper so it is properly aligned and the entire page is included in the scanned image
  • If the scanned record is of poor quality and is not clearly readable
    • Reset the dpi (dots per inch) setting on the scanner to a setting higher than 300 dpi and scan again
    • Keep increasing the dpi until the record is as readable as possible
  • If the condition of the original paper record precludes a good quality scanned image from being produced
    • Document the problem on the scanned record and indicate that the paper copy has been maintained and where it is located
    • The Clinic or the department will keep both the scanned record and the paper copy of the records that did not scan well

4. Filing Scanned Records

The School of Dentistry has daily incremental backups of data stored onto its servers.  If a file is deleted or moved, the school’s system administrator can retrieve those backups up to 60 days from deletion.  If a file is changed, up to 6 previous versions are retained for 45 days.

5. Procedure for Scanning Documents

All documents will be scanned according to a standard procedure to ensure documents are scanned into the correct patient record.

  • Select appropriate patient name, date of birth or record number in axiUm using the rolodex module
  • Correct patient name must appear on the bottom of the screen before starting the scanning process
  • Under the Electronic Health Record module, select ‘attachments’ and under the ‘section’ tab select the appropriate clinic or department and select ‘images’ for radiographs
  • Select ‘Create New Record’ and add the ‘Description’ which will include type of document and date of document
  • Attach the scanned document by clicking on the ellipsis and select ‘OK’
  • Confirm that the document has been appropriately scanned into axiUm
  • If all scanning requirements outlined in this policy have been met, then the paper copy can be destroyed

6. Modifying Scanned Records

It is important to ensure that the original content of a scanned record is not altered or modified once it has been finalized.  Scanned records should be “read only” to ensure that there is no improper alteration or modification.

7. Computer Security Standards

Ensure that the unit I-drive folder where files will be stored is a secure folder only available to those who need access to the records stored there.  It is critical that managers promptly notify sodit@uw.edu when an employee separates from their unit, so access capabilities can be removed.

All incidents of potential HIPAA Privacy and Security breaches should be reported immediately to the unit supervisor and the School of Dentistry Compliance Director.  In addition, the Compliance Director should report the following Security breaches immediately to the appropriate authorities:

  • Incidents involving national security information or national security systems to the University Facility Security Officer at 206-543-1315 or uwfso@uw.edu
  • Incidents involving protected health information to the Executive Director of Health Sciences Administration
  • Incidents unrelated to national security information, national security systems, or protected health information to the Office of the University Chief Information Security Officer (CISO)

8. Record Filing and Identification

Files containing scanned documents subject to the retention requirements of this policy will be stored only on approved network storage, which is located on the “\\sod\files (T:)” drive. A folder for each department will be established on this drive and will contain Individual folders for each fiscal year (for example FY2015-2016), and each fiscal year file will be composed of monthly folders. Once a document is scanned it will be placed in the appropriate fiscal year and month files with the appropriate title, date, and patient name and record number.

9. Retention Requirements of Scanned Record

All records have a specific amount of time they must be maintained.  This specific amount of time is called a “retention period.”  Retention periods are based on the content of a record. Retention periods are found in the “University General Records Retention Schedule.”  Retention periods included in UW General Records Retention Schedule apply to all records regardless of their physical form or characteristics.

  • The paper record can be destroyed after it is scanned according to the technical requirements outlined in this document
  • The retention period which would have been applied to the paper record must instead be applied to the scanned record in axiUm
  • When it is not possible to create a readable scanned image, the School of Dentistry will keep the original paper document for the full retention period

10. Records Retention Process

An audit to identify and approve the deletion of records that have reached the end of their retention period will be conducted during the summer quarter annually by the Records Department.  A  report will be run through axiUm that lists patient records that have reached their retention period. Records cannot be deleted until the records retention schedule has been met and the department manager has approved their deletion. The staff person in the Records Department will delete the records and place a list of those records in the “Deleted Records” file.

11. Migration and Preservation Strategies

Patient Records from axiUm are stored on an Oracle database.  Oracle has been the leader in database software and the School has the ability to migrate data to and from the Oracle database.

12. Scanned Documents Storage and Backup Policy

Network storage containing these scanned documents will be included in the department’s backup schedule for business-critical data.  The School of Dentistry servers are backed up every business day by UWIT, who then stores the back-up data in two separate data centers, each in a different seismic zone.

Appendices:   Appendix A, Clinical Records Applicable for Electronic Scanning

Joel Berg

Dean of the UW School of Dentistry

October 13, 2016

Appendix A

Clinical Records Applicable for Electronic Scanning

• Anesthesia/sedation logs
• Authorization to release PHI
• Chart Notes from Outside Clinic
• Fee waivers
• Insurance Cards
• Insurance Correspondence
• Insurance Explanation of Benefits
• Lab Prescriptions
• Lab Results
• Legal Correspondence
• Medicaid “Agreement to Pay” forms
• Medicare Advance Beneficiary Notices
• Patient Correspondence
• Patient Diaries
• Patient Identification
• Periodontal Charting from Outside Clinic
• Pictures of Patient
• Pre-Authorization
• Pre-Determination
• Referrals from Outside Clinic
• Treatment Correspondence
• X-rays from Outside Clinic