IGSOP08 Record Scanning Procedure by Provide Community

Record Scanning

Standard Operating Procedure

Version: V2

Ratified by: Quality & Safety Committee

Date ratified: 23/08/2021

Job Title of author: Information Governance and IT Projects Manager

Reviewed by Committee or Expert Group Clinical Reference Group

1. Introduction

Before a decision is made to scan a record type into an electronic medium and destroy the original, consideration must be made regarding

• The cost of scanning compared with the cost of retaining the records in original format e.g. reduced storage requirements and business efficiency

• Whether the record is in a format suitable for scanning

• Whether the records are of any archival value and there needs to be consultation prior to destruction

• Format of preservation: scanned records must be retrievable should there be an improvement in information technology

• The need to protect the evidential value of the record.

2. Before Scanning

• Create a Register of all complete records scanned (i e when archiving records). This is not required when scanning individual documents

• Establish that it is the original record, if not it can be destroyed

• Establish that it has not past the retention period (refer to the Records Management Retention Policy)

• Calculate how long the records must be kept for

• Check there are no wrongly filed documents*

• Remove any staples or paperclips.

• Check for post it notes and that there is enough space to secure to the page without obscuring any other text, use sticky tape to do this. Otherwise, secure to the reverse of the page if space is available

• Check for ultra-shiny fax paper - this will not scan properly and needs to be photocopied before being scanned

• If forms are folded then these will need to be divided into separate pages and kept in order

*Please note that in the case of patient records, scanning incorrect pages regarding another patient into a patient’s record constitutes a confidentiality incident and a breach of Data Protection Legislation, so please be careful.

3. What to Scan

The whole file records should be scanned (unless it is simply not possible to do so) because there is risk where information is stored in two different places / media.

4. What Not to Scan

Where information is to be scanned into SystmOne an assessment must be made as to whether doing so could cause a future breach in confidentiality, particularly if the record contains information about third parties.

5. Where to Scan

Consideration should be made as to where records should be scanned to i.e., saved. Active patient records should be scanned to the relevant Electronic Patient Record system, such as TPP SystmOne or Inform.

Archived patient records should be scanned to the relevant Electronic Patient Record system, such as TPP SystmOne or Inform. Where there is no such relevant system available, records should be scanned into a BIP0008 compliant system such as WinDip.

Corporate records defined as documents with ‘wet’ or electronic signature should be scanned to the Provide shared drive (R:) and stored in folders that are clearly named and have access permissions set to only the staff that require access, requests can be made to IT to check or update access. Shared folders are not protected from editing or deletion and so where absolute proof could be required that documents have not been altered, a BIP0008 compliant system such as WinDip should be used.

6. Quality Check Scanned Images

Once the batch has gone through, it is necessary to check a sample to ensure that:

• All the images have scanned

• All the images are legible, particularly that:

• All signatures and dates on the original document can these be picked up on the scanned image

• Date stamps are visible after scanning (red ink does not scan well)

• At least three images in each batch of 50 should be checked to ensure the quality of the image

7. Indexing of Scanned Records

Where applicable, scanned records must be indexed appropriately to aid easy search and retrieval.

Records scanned into SystmOne should be scanned and indexed in such a way as to aid fast and efficient retrieval.

When scanning into WinDip indexes must be set up prior to scanning. Although WinDip contains the ability to use free text searches for documents there is the obvious drawback that this may bring back large volumes of returns, thus this should not be relied upon.

Example approved indexes are as follows:

• Indexing for the HR records

• Forename

• Surname

Indexing for clinical Patient records

• NHS Number

• Forename

• Surname

• Date of Birth

8. Disposal of Paper Records

Once the images have been scanned and quality checked, the original paper records can be disposed of as ‘confidential’ waste unless any of the criteria below are met.

Best practice is to wait until the scanned image has been processed and included in at least one back-up cycle:

For Scanning into Windip, the record can be destroyed 24 hours after scanning.

For Scanning into SystmOne: this is when the image has disappeared from the 'not on server' page and is generally within a few minutes of scanning but can be several hours if doing a high quantity of scanning.

If scannining into other systems please check with the system supplier/ support team to ascertain when the backup is completed to enable destruction of the paper copies.

Paper records scanned onto an electronic system should not be retained as a backup, notwithstanding the above timescales and the instances described in section 9 below.

9. Records Which Should Not be Destroyed Once Scanned

If there is an on-going complaint, Freedom of Information Act request, Data Protection Act request or legal claim anticipated, the original documents should not be destroyed.

Similarly, if a claim is on-going the original records should be retained and there is usually a standard direction from a Court at the first Case Management Hearing to that effect.