Scanning Strategy

1. Protocol to Retire Paper Chart via Abstraction

Protocol to Retire Paper Chart via Abstraction

Overview

Table of Contents
1. 1. Protocol to Retire Paper Chart via Abstraction
Open paper chart and (if present) place the printed summary into view.
Make certain that all significant information that is written or dropped in to the chart, within the past 3 years, has been entered into the EMR. Certain items such as multiple protime reports and related calls, multiple paged reports, etc. will not need to be stored in their entirety within the EMR.
Generally, it is only necessary to enter the last 2 to 3 of multiple reports. Add IMPORTANT information that is more than 3 years old to the EMR.

Create a List of Items Older Than 3 Years to Enter Into EMR

Allergies or reactions to medicines (allergy field in summary)
TB skin tests
EEG reports
Echocardiograms (Interpretation, Ejection Fraction)
Most outside reports and consults
Immunization records
EKG’s (if none in electronic chart). Scan only the most recent EKG
Growth chart (if patient less than 12 years old)
Pathology Reports
Radiology reports
CT reports
MRI reports
Ultrasounds

Create a List of Items Not Bring into EMR

Medicaid Prescription Drug Program forms
Department Human Services Forms
Health Insurance Information
Home Health Reports
Managed care referral forms (e.g. Cigna, AETNA, Medicaid)
Refills requests (faxed)

Summarizing/Abstraction

Here is just one example of a commonly implemented protocol:

At the top of the interventions field, enter the code “pp.” This puts the text “Paper Chart Archived” into the field. Then Control-D enters the date. Finally, place your initials. The first line of the Summary Interventions field might appear as:
Paper Chart Archived – 11/30/2007, MK.
Then place an “*” into the Title field of demographics.
Highlight the name on the paper chart (e.g. pink highlighter) to indicate that it has been retired.

Samples of Data in the Summary Interventions Field After Paper Chart Retirement/abstraction

    Paper Chart Archived – 11/30/2007, RO.
    3/4/2007: Lasix prn x 1yr.
    10/15/2006: Normal carotid ultrasound.
    10/13/2006: Wellness exam, Dr. Welby.
    5/2007: Pyuria on Ua, Bactrim.
    2006: Flu shot.
    9/1997: Possible GERD, Prilosec.
    1999: USGB.

Above, in each line, notice the first item is the date, then a dash, then the information.
Enter items sequentially with the newest information at the top and the oldest at the bottom of the listing. In general, information the past few weeks should include the exact date, information (e.g. 10/15/2006: Normal carotid ultrasound.)
Information from the past few months should include the month & year (e.g. 5/2007: Pyuria on Ua, Bactrim).
Information several years old only need to indicate the year (e.g. 1999: USGB).
If the test, procedure or exam is normal, then no further comment is necessary.
If there is an abnormality, then indicate such (e.g. Pyuria on Ua). If there are more than 2 abnormalities on a report, then it may make sense to scan it rather than typing in comments.

Create List of Abbreviations

These are included only as examples. Use what is common in the practice. Because the intent is to be able to delegate this task to a non-clinical person, a comprehensive listing can increase efficiency and consistency.

CXR = chest x-ray
US = Ultrasound
GB = Gallbladder
Ua = Urinalysis
GERD = gastroesophageal reflux disease
CBC = complete blood count
GHP = general health panel of blood tests
TSH = thyroid stimulating hormone blood test
EKG = electrocardiogram
EEG = electroencephalogram
Prn = as needed
tid = three times daily
bid = two times daily
qd = daily
hs = at bedtime
pc = after meals
ac = before meals
wnl = within normal limits
Lipids = blood test for cholesterol, triglycerides, etc.
CMP = Complete metabolic panel of blood tests
Exec = Executive panel of blood tests
LS = lumbosacral or low back