As you take your practice, clinic, or hospital paperless, you will be confronted with a number of questions about what to do with your existing paper charts and how exactly you go about scanning those medical charts that are the backbone of your business.
For the purposes of this article, let’s assume that the reader already understands all of your legal responsibilities relative to the retention schedule for your charts.
Charts should be kept a minimum of several years after a patient’s last visit. There are only two ways to preserve the charts ‐ store the paper or scan and convert to digital charts. You can store charts on‐site or with a reputable document storage company. It is very risky to store your charts at a self‐storage facility or worse yet, in your basement. A reputable facility will have fire suppression systems and protection from water. Self‐storage facilities go up in smoke regularly (Try a Google search for “self storage and fire”). Monsoon rains that strike the DC area yearly showed the vulnerability of basement storage.
There are 3 reasons why practices scan their charts.
Should you scan all the charts, and everything in each chart?
There are a variety of considerations including medical necessity, legal, and cost.
If you have been properly purging charts as they become eligible for destruction, then yes, you should scan all of your charts. Your electronic charts are to be treated just like the paper charts from a retention perspective. If you have been holding on to all of your charts, then you will likely be able to purge everything outside of the retention period, and only scan the newer charts.
Each practice is different, and each physician will make the determination of what is medically necessary to scan, and what can be destroyed via shredding. At minimum, all records that reflect the clinical care provided to a patient, including provider notes, nurses’ notes, testing, and medical lists should be kept. Billing records that reference care provided should also be scanned and preserved along with the rest of the medical record.
Legally, you must consider what would be necessary to keep in order to properly defend yourself in a medical malpractice lawsuit. Some practices will scan the entire chart, and every scrap of paper in it, while others are quite comfortable just scanning what is absolutely legally and medical necessary.
Maintaining medical records in any format will cause you to incur some cost. Scanning yourself or hiring an outside scanning service company, you will need to consider the costs of scanning. The costs are variable. For example, charts can be scanned and OCR’d (optical character recognition), meaning they can be made searchable. In many instances, it is not necessary to OCR a chart because there is no typewritten text that is worth searching. Or the chart may be so small that it is very easy to simply browse the PDF. You likely don’t need to pay for OCR. Another way to cut costs is to make sure carbon copies of labs and other forms are destroyed and not scanned.
It’s an excellent question. If you are to undertake the scanning project in house, you will need a few things. Secure office space where a scanner and a computer can be set up, a 4‐6 foot table where the charts can be prepared for scanning, and 1 or more people dedicated to the project. The process is fairly simple.
The other choice is to select a document scanning service company.
The process is the same as above, except the work is generally performed off‐site in a secure facility. A scanning service company provides the following benefits to their clients:
After scanning, you can use them with your EMR.
Some practices will simply put the charts on the Windows File System so that they can be viewed when needed. Others will import some or all of the charts into the “Notes” or “History” tabs in the EMR. The most common strategy is to save the charts to the file system, and only import the chart into the EMR the next time the patient comes for an appointment.
Visualize an empty file room, with no employees pulling charts, filing charts, looking for loose pages and lost charts.