Electronically Scanning Client Information 

BACKGROUND 

Jason is an OT practicing psychotherapy in a mental health facility. As part of each new session Jason uses standardized paper and pencil screening assessments. Jason often use worksheets as part of the clinical intervention with his clients. Up until now Jason has been summarizing these clinical assessments and interventions in the clinical notes and he securely maintains the original paper copy. The organization has implemented a new electronic medical record system. Jason wonders if he scans his paper assessments, is it also necessary to retain the original paper copy or can it be destroyed?

CONSIDERATIONS

  • Jason considers the purpose of record keeping. He understands that a client record is a medical legal document and a source of evidence and accountability. He is aware that the primary purpose is to officially record events, decisions, interventions, and clinical plans. The College’s Standards for Record Keeping is a resource and outlines the minimum expectations for all occupational therapists. 
  • Jason considers if there is a need to retain the original clinical data and wonders whether in the absence of this original data would his documentation stand sufficiently alone.   To gain additional information he goes to the College website, and under Standards & Resources he reviews the Standard for Record Keeping. 

  • Jason questions whether his organization has any requirements that the original data be maintained.

OUTCOME

  • Jason considers the content of the paper and pencil assessment forms and determined that the existence of the original data may add credibility and supports his recommendation.  
  • Jason reviews Indicator 3.8 of the Standards for Record Keeping regarding the inclusion of electronic clinical data. In the Standard it states that “converting data to an electronic format, for retention purposes, is appropriate as long as the integrity of the data is upheld.” If transferring the data would alter its integrity then it would be better to retain the hard copy, with a notation in the electronic health record, indicating its existence and where it can be found. 
  • Jason decides to scan the assessment data and selected worksheets and save it in the client’s electronic clinical record. He uses his clinical judgement to determine what data are best summarized in written format and what clinical data are best represented by an image. He acknowledges that in circumstances where the quality or completeness of the data is not optimal then he will note where the original data is kept for reference.

DISCUSSION

The College expects that OTs use their clinical judgement and rationale when determining if clinical data is appropriate to scan into a client’s electronic clinical record. Health Information Custodians (HIC) do not need to keep multiple copies of the exact same personal health information. If the integrity of the data is kept intact during its transition to the electronic format, it is reasonable to assume that a scanned version of the personal health information is essentially the same thing as the paper copy.

Organizations will often have policies and procedures that OTs are also expected to adhere to when including electronic data into the clinical record. If an OT determines that the data does not need to be kept the destruction of personal health information should be completed in in a secure manner as outlined in the Standards for Record Keeping – Standard 7 - Retention and Destruction and organizational policies.   

REFERENCES 

CONTACT

If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or practice@coto.org.

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