Medical Records: Evaluation, Digitization, and Outsourcing
5 Evaluation, Selection, and Destruction of Consignment Notes
The process of evaluation, selection, and destruction of the consignment note must be made prior to the migration to another medium. The healthcare world uses two different techniques: microfilming and digitization.
- Microfilming: The support is microfilm.
- Digitization: The supports are magnetic and optical discs.
Before making the change of support, the Health Care Center (HHCC) and having completed the weeding, should check that documents are sorted correctly according to the rules of the center and that they correspond to the episode to be scanned or microfilmed. Once the change of medium is made, the originals must be destroyed immediately. The elimination of documents does not take place, however, if miniaturization techniques are used as backups for the original paper.
With the replacement, the legislation is not very clear. Documents not microfilmed or digitized have no legal value, as new technologies allow modifications of the information contained in electronic files.
Microfilming Process
- Microfilm: Exposure of documents in microfilm.
- Processing: Processing of the film for its readability and conservation (developing, fixing, washing, and drying).
- Editing: Presentation of the microfilm in a particular format (cartridge, roll, microfiche, jacket…).
The presentations of microfilm are varied, but in the medical world, the following are used:
- Roll-Film: 35mm can be used to microfilm X-rays or 16 mm used in clinical documentation on paper. The rolls are listed consecutively and stored in order; within the scroll, each image has a definite position that is referenced in the database file for later retrieval.
- Microfiches: Microfilms are sheets of 15×9 cm. The document tracking system is the same as in the previous case.
- Jacket: This is a pack comprising 2 sheets of thin plastic welded in introducing the films. They are generally used for the presentation of X-rays.
If asked for a microfilm, proceed to search the roll of film that contains it. From here, place the roll within the reader device. Through a keyboard, introduce the position of the paper; this is automatically located and displays. We find the requested document, and a copy is made on paper so it can be used.
B-Scanning
Digitization involves passing a document on paper to a computer-readable electronic file.
To carry it out requires a scanner to capture images and a computer for viewing, processing, and recording on magnetic media (hard drives) or optical media (CD or DVD) with high storage capacity.
Most users use optical media, CDs, or DVDs, which are listed consecutively and kept tidy. In the database of the hospital computer system and through the file manager program, the digitized HC is referenced to the CD or DVD that contains it.
If an HC is requested that has been scanned, the search proceeds to the CD or DVD on which it is recorded. It is read with the computer via the software, and a copy is made on paper using a printer.
6 Outsourcing of Clinical Archives
Outsourcing is a management tool that is being introduced gradually in healthcare organizations and is the outsourcing of a service previously provided from within the organization. In the case of the files, it is necessary to hire an outside company that ships HHCC stores and manages its own query, while ensuring their safety and monitors their status and conservation conditions.
The ultimate responsibility for the documents remains with the clinical records of the health care provider, and the subcontractor has no power of decision on the documentation that has left him in custody.
Usually, liabilities and historical files are outsourced, although there are cases of total outsourcing service file.
The HHCC is requested by telephone, fax, or email, and the contractor serves it with a delay of 2 or 48 hours, depending on the urgency of the request.
When deciding to outsource the file, one must act on a protocol that allows:
- Select the documents of the activity or inactivity of the HC (or other criteria that the center considers).
- Compile a list of documents that will be transferred.
- Draft a manual on rules of conduct that meets all of the information concerning the responsibilities of the health care provider and business.
- Write a record of transfer witnessing the departure of the documentation center.