If you work in a hospital or doctor’s office, you need to understand the basics of medical record scanning. More and more healthcare providers are putting technology to work for them when it comes to patient charts. Medicaid and Medicare now offer incentives for providers who keep their patients’ medical charts on computers rather than on paper. As a result, knowing the ins and outs of medical record scanning is essential for those who work in healthcare.
What does EHR Stand For?
EHR is the abbreviation for electronic health record. The term electronic health record used to refer only to an office-based patient documentation system. However, this is now the definition of an EHR:
EHR = EMR + HIS + CIS + CPR (Electronic Health Record = Electronic Medical Record + Health Information System + Clinical Information System + Computerized Patient Record)
According to the Centers for Medicare and Medicaid Services: “An Electronic Health Record (EHR) is an electronic version of a patient(‘)s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that person’s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.”
in other words, an EHR is the total of a patient’s medical history stored in a computerized database.
Manual Patient Charts vs. Electronic Medical Charts
Patient charts that are kept on paper the old-fashioned way have a variety of downfalls. For one, they can only be viewed by one person in one location at a time. When another physician at a different facility needs to access a patient’s records, the chart must be copied and delivered. This takes time. It also means that in an emergency, the treating physician probably won’t have access to a patient’s medical information. This could quite literally be the difference between life and death.
There are also costs associated with the paper and ink in addition to the person’s salary who is responsible for finding, copying, and delivering the records. Not to mention that because only one doctor has access to a patient’s chart at a time, records often become fragmented. When a specialist at one facility updates a patient’s chart, that information doesn’t usually get added to the records kept by the patient’s other doctors at other facilities. In addition, records kept on paper are fragile. Water or fire can easily destroy them and even normal use can cause damage over time.
In contrast, electronic medical charts are accessible to any number of doctors simultaneously, regardless of their location. Electronic records update in real time. Patients’ test results are available to all of their doctors immediately. The ability to have records available in real time is particularly helpful for patients with chronic conditions who require an entire team of healthcare professionals. In emergency situations, treating physicians are able to access a patient’s vital medical information immediately. This is true even if the emergency occurs far from the patient’s home. Electronic medical records also have the advantage of being safer. Water or fire can not as easily destroy them.
Scanning a Medical Record
Health information management (HIM) professionals receive the following best practices guidelines for medical record scanning. These steps ensure that the records are of the best possible quality.
Step 1: Prep the record
- Remove all staples, dividers, paperclips, etc.
- Smooth documents and separate any that may stick together.
- Ensure documents are in order.
- Verify that all documents belong in the record.
Step 2: Index the record
- Index documents according to type.
- Validate correct patient name on all documents.
- Verify that patient listed on the paper chart is the same as the patient on the EHR.
Step 3: Scan the record
- Fan through or shake out the documents to make sure no staples or paper clips are stuck.
- Begin scanning while watching the quality of images on the screen.
- Clean the glass on the scanner if a line appears at the top of the scanned pages.
- Put your initials on the date on the cover sheet.
Step 4: QA the record
- Have employees QA each other’s scanned records.
- Verify the patient name, medical record number, and date of service are correct.
- Confirm that this information is consistent on all remaining documents.
- Re-index as necessary.
Medical Records Scanning
There are a variety of companies that specialize in medical record scanning. This is particularly helpful for hospitals and doctors offices when they first switch over from paper medical records to electronic health records. Scanning in a large number of patient charts is more time consuming than many healthcare facilities can afford. These companies give healthcare facilities confidence that medical records are scanned in correctly and are of good quality.
Typically, the cost of medical record scanning is somewhere between $.05 and $.15 per image. These costs can vary based on the total Volume of pages to b scanned, the amount of preparation required, and the number of index fields requested. Services provided by these companies can include the following:
- Preparing the documents for transport to Shoreline’s Production Scanning Facility
- Receipt of documents
- Document preparation
- Quality Control
- Importing your data into your Electronic Medical Records (EMR) or Electronic Health Record (EHR) System
- Inventory of your documents and disposition
Using a Medic Scanner
Progress notes and test results are not the only things that require scanning into a computer when using an EHR system. Insurance cards are on the list, too. Medic scanners make this process quick and painless. There are a variety of models available to fit the needs of every health care facility, no matter how large or small.
Medical Record Scanning: Easier Than You Thought
Once accustomed to old-fashioned handwritten medical records kept on paper, switching to electronic health records is daunting. However, taking the plunge can benefit both patients and providers. Although it may be intimidating at first, medical record scanning is far easier than you ever thought it was
Featured image Public Domain, by the National Guard via Flickr