November 13, 2009
Paper Chart to EMR Scanning List
Written by: John- EHR
- Electronic Health Record
- Electronic Medical Record
- EMR
- EMR Implementation
- EMR Technology
- HealthCare IT
I’ve previously written about chart disposal after an EMR implementation and the concept of “thinning your paper chart for scanning into an EMR.” Because of those posts, one reader asked me about feedback on a list of what things should be included in the “thinned” paper chart.
Of course, my first reaction was to tell them to ask the doctors. Each doctor/specialty/clinic is unique and so every one of those would have their own list of what they thought was important. However, I also said I’d post their list on here for people to take a look at and provide feedback on things that shouldn’t be on the list or things that might be missing from this list. So, check out this list and I’d love to hear feedback on it in the comments:
Paper Chart to EMR Scanning List (in no particular order):
Birth records, Nursery, NICU, State Screen, Type/cross.
Growth Charts front and back.
Immunization record (multiples may exist, scan all).
Master Problem List.
Chronic/incidental/PRN medications.
Allergies/sensitivities.
All prior well child checks.
School/Scout/etc PE’s.
All acute visits if chronically ill, otherwise do not include uncomplicated CCD.
All special evaluations (ADHD/Feeding/Nutrition etc done in house).
All referral and specialists’ consults/findings.
Family History if known. Adoption may prohibit this.
City water vs well water.
Lab reports – baselines and all if chronic medical issues.
All diagnostic imaging reports.
Insurance history.
Demographic sheet/all address changes.
All legal documents – custody/state/adoption/POA/living will etc.
A look at this list makes me think about what types of things might be useful when exchanging patient records electronically. Seems like the concept of thinning the chart and exchanging data might be worth considering together.
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12 responses to "Paper Chart to EMR Scanning List"
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Looks good. Thanks.
There are a number of applications that can aid in this process and make the record scanning process a breeze through the use of barcode cover sheets. Place them in the scanner and have them auto-routed to patient folders.
Can anybody comment on Scanning guidelines in regards to time? Is it a personal decision as to how many years worth of MRI, Xray, Consult notes, OP notes etc.. We are currently planning on going back 2 years with most studies and notes. Suggestions?
This is a large system with specialists and GPs
Thank you.
Anderson,
It’s really a personal decision based on what the provider wants available to them. Some want longer based on their specialty and others don’t really need much at all.
There are data retention laws, but those vary state by state. So, you should take into account how long you have to keep those documents when you decide what to scan also.
John –
I was hoping that you would continue your blog on the link between documents that should be scanned and the need to exchange these same documents. Any additional insights?
Therasa,
I think you should take a look at this video which talks about exchanging documents and other clinical data: http://www.emrandhipaa.com/emr-and-hipaa/2010/03/15/video-interview-about-verizons-hie/ It’s an interesting move to exchange all sorts of clinical data.
Thanks John!
Funny you should point me to this. We are a part of the Healthstory, which is comprised mostly of transcription vendors. MD-IT, Inofile, and Fujitsu are working through a solution now that will connect the latest Fujitsu network scanner (ScanSnap FI6010N) to the Verizon exchange….similar to fax.
It is the feeling of the group that following an incremental course to interoperability by getting all to exchange documents and data now, despite their current IT position in house. Using base CDA standards (latest ballot released from HL7 for unstructured document which incorporates elements from the CCD header into an unstructured document) and slowly moving to advanced and fully structured data and documents has been the course outlined by this group.
Enjoy your blogs!
Therasa,
I agree with that also. Better to get everyone connected and talking regardless of what’s being “said.” Then, you can start adding on increasing layers of structure.
John, Can you offer me your name and an email or can you shoot me an email ..would like to discuss digitizers and scanners. Joe
Hi Joe,
I’ll drop you an email with my contact info.
Hi John,
Could you pass me your email address? I’m initiating a health records scanning pilot project and would like to discuss lessons’ learned, etc. Thanks Christine
Hi Christine,
I’ll send you an email now.