Scanning and uploading of documents briefing paper

Transcription

1 Scanning and uploading of documents briefing paper Introduction With the implementation of the Trust s new Electronic Patient Record (EPR) system, RiO, there will be an increased need for paper documents to be scanned and uploaded to an individual s record. In brief, it is important that during this process: all documents are scanned to a standard that they will be able to be opened and read on the EPR system the correct documents are uploaded to the correct patient s records these uploaded documents can then be found and retrieved by those who need to refer to them Where scanning is used, the main consideration is that the information can perform the same function as the paper counterpart did and like any evidence, scanned records can be challenged in a court. This is unlikely to be a problem provided it can be demonstrated that the scan is an authentic record and there are technical and organisational means to ensure the scanned records maintain their integrity, authenticity and usability as records, for the duration of the relevant retention period. 1 The legal admissibility of scanned records, as with any digital information, is determined by how it can be shown that it is an authentic record. An indication of how the courts will interpret evidence can be found in the civil procedure rules and the court will decide if a record, either paper of electronic, can be admissible as evidence. 2 Process The actual process for scanning and uploading documents onto RiO will vary depending on the requirements and administrative processes defined by individual Services but the key principles should be the same. Services need to ensure that local processes are documented and all staff involved in the process understand the importance of taking care when scanning and uploading documents to ensure the right information is available in the right patient s records. Quality checks must be a part of these processes. There are two stages to the process, one will be the scanning and/or preparing a document to be uploaded. This may involve the scanning of a paper copy of a document or the saving of an electronic file created or received. The second stage of the process is the actual uploading of the file to the patient s record in RiO. Scanning/preparing a document for upload It is important that any document being scanned and/or saved in readiness for uploading is saved using the file-naming convention of including the patient s name and NHS Number detailed in this section. This is so the file can be checked against the patient s name when in the upload screen in RiO. This section details the 1 Records Management Code of Practice for Health and Social Care: Scanning and uploading of documents briefing paper v2.0 Oct 2017.docx 1

2 process for a scanned document but the file-naming and saving conventions are the same for any electronic records being prepared for uploading. 1. Prepare document for scanning e.g. date stamp, all pages same way round 2. Scan document and save to network Document Uploads folder on your computer/network drive, using the file naming convention: Patient s LAST NAME First Name NHS Number Document type date of document dd-mm-yyyy e.g. SMITH John Referral This file naming convention will help identify the correct document to be uploaded. 3. Open scanned document to confirm document has been scanned successfully and all pages can be read and are correctly orientated i.e. the right way up 4. Store original document in readiness for confidential destruction once the quality checks have been carried out on the uploaded document Uploading to RiO 1. Open Patient record in RiO and select the Document Upload option (see screenshot below) File: Browse on network drive to locate uploaded document. Patent name and NHS number are first in the file name so these can be checked against the patent details above in RiO The Author will be the author of the document being uploaded. Document Title is the document description e.g. IDT Referral , SLT Assessment etc. see Appendix 1 Date document was created. Documents should be date stamped on receipt so scanned copies have this date in them. Document Type: select the Service/Specialty Description: add additional information relating to the document that will assist in identifying it for retrieval or for noting any relevant comments relating to the document 2. In the Document Upload dialogue box select Browse in the File field and locate the patient s scanned document. 3. Check scanned document filename matches the patient s record 4. Enter Author s details e.g. Dr Sam Browne 5. Enter Document Title: title of document so that it can be identified and retrieved when required. Latest guidance is to include a Service/Specialty prefix, the type of document and the date e.g. IDT referral or SLT assessment (see Appendix 1 for further examples of suggested document titles). Scanning and uploading of documents briefing paper v2.0 Oct 2017.docx 2

3 After this initial document title you can include a short description of the content of the document to assist in identifying the document. Note: this Document Title will not only assist you but other members of staff in finding the document. There is no need to use the patient s name in this title as you are in that patient s record so will only be shown documents relating to them. 6. Enter Document Date: this is the date the document was created 7. Select Service/Specialty from the Document Type dropdown list. Select the service that this document relates to. Document Types will be the name of the service, with the exception of Safeguarding and SEND which are trust wide services. 8. Description: Add additional information relating to the document that will assist in identifying it for retrieval. This can be additional information relating to the actual document e.g. GP referral received from Dr Livingston, Stanley Place Medical Practice or it can be used to note a delay in receiving the actual document e.g. letter dated 23 July 2017 but only received on the 14 August If the original document you are scanning is of poor quality this should also be noted in this section. 9. Select Upload Document 10. On completion of upload open the document in RiO to view it and check it is correct and refers to the right patient 11. Once the quality checks are complete the original paper copy can be disposed of (see section below) and the scanned copy on the computer/network drive can be deleted Document View When searching for a document, select Document View from the Clinical Documentation Icon options. You can view the Document Description for the selected document from here. This will help to identify the relevant document. Uploading Documents via RiO Drop Zone The above guidance on the document title, description, document date and type are the same when you are creating a document from within RiO and using the RiO Drop Zone to upload it into a patient s record. Scanning and uploading of documents briefing paper v2.0 Oct 2017.docx 3

4 Access Restriction Settings Lock option In some cases documents uploaded to a patient s record may require restricted access where only specific staff or teams can view these documents e.g. Psychology Tests; Safeguarding Child Protection/court reports. RiO has a Lock option where those who are able to view the document can be set via the Lock>Lock Settings function. This Lock function also has an option of Locked with indication or Locked without indication. When a document is locked a padlock icon will be displayed next to it. Those with the relevant permissions can unlock a document by clicking on the lock icon. Actions to be taken if a document is uploaded to the wrong record If a document is uploaded to a patient record in error it can be removed by selecting the Document Removal option under the Clinical Documentation icon. You will then need to trace the incorrect document and in the Removal Reason select Added in Error For further information and guidance on removing documents there is a RiO Problem solving guide - Removing documents: Solving%20Guide%20-%20Removing%20Documents.pdf Disposal of Original Paper Documents Original paper copies of the document should not be destroyed until the scanning and quality checks have taken place and the system has gone through a back-up phase (for RiO, the back-up is carried out continually to a second server so data is backed-up at all times). Once a document has been scanned, uploaded and quality checked the uploaded copy of the document can then be considered as the primary record and the, now secondary, paper original can be disposed of under confidential means. This disposal process should be included in local processes. Guidance on the time period will depend on any specific requirements within the Service but in most cases this can be done at the end of that day. It would not be expected for these secondary copies to be retained for longer than a week as there is a risk of a backlog building up and that these documents are not stored securely. Scanning and uploading of documents briefing paper v2.0 Oct 2017.docx 4

5 Scanning Quality: A scan of not less than 300 dots per inch (or 118 dots per centimetre) as a minimum is recommended for most records although this may drop if clear printed text is being scanned. It is, therefore, recommended that all scanning should be carried out to the following resolution settings: Black and White document 200 DPI (Dots Per Inch) Coloured document 300 DPI Photographs 300 DPI If the original being scanned is of poor quality in the first place this should be noted in the Description filed of the RiO Document Upload window. The check on quality of the scanned image should include viewing it on RiO and zooming in of specific areas of text to ensure they are clear and legible. Do not dispose of the original document until these quality checks have taken place and the document has been viewed and checked within RiO. Format of Scanned Documents: for documents PDF (Portable Document Format) for photographs JPEG (Joint Photographic Experts Group) Quality Scans: common mistakes to avoid: References Only scanning one side and not both sides, including blank pages Document not straight in scanner Scanning a copy of a copy leading to a degraded image Scanning at a lower DPI than recommended, leading to a poor quality image File name of the scanned document not in the recommended format which leads to it being uploaded to the wrong patient s record on RiO Clinical Record Keeping Policy: British Standards Institute - BS Evidential Weight and Legal Admissibility of Electronic Information: electronic-information-management/ Records Management Code of Practice for Health and Social Care: Health-and-Social-Care-2016 Scanning and uploading of documents briefing paper v2.0 Oct 2017.docx 5

6 Appendix 1: Common Document Titles The table below lists common document titles that can be used within the Document Title prefixed by the Service Speciality abbreviation and followed by the date of the document e.g. SLT Assessment Document Description Assessments Care Plans Clinical Investigations Example Tool End of Life, Diabetes Care plans etc X-ray, Bloods Biochemistry ; Bloods Haematology; Bloods Microbiology; Radiology; ECGs; Scans Consent DNACPR External Agency Images Interventions Legal Letters Referrals Reports Observations Outcome Measures Forms, to photograph; to share information; treatment Completed Do Not Attempt Cardio Pulmonary Resuscitation form/document 3 rd Sector Referrals; Advocacy; Risk Assessment Charts; genogram; photograph Copies of Paper Documents used Correspondence; Court Appointed Deputy; Lasting / Enduring Power of Attorney; Deprivation of Liberty Safeguards; Mental Capacity Act (MCA); Advanced Decision / Directive Change of Medication; correspondence to client and/or GP/and or referrer Referrals received; Proforma (e.g. TRAQS TeMS); GP Summary OT/Physio/Speech and Language Intentional Rounding; Special observations Patient Reported Outcome Measures (PROM); Clinical Outcome Measures Scanning and uploading of documents briefing paper v2.0 Oct 2017.docx 6