This Management Policy must be able to demonstrate the integrity of the system either through inclusion of, or by linking to:- Details of acceptable and unacceptable file formats A security and access control policy; Standard operating processes and procedures including a system description manual (which would usually be supplied by the vendor) An auditing procedure and documentation of relevant outcomes to support the claim that the system is working normally. Similarly routine maintenance and replacement of worn parts of the scanning equipment is essential. Practices should have in place procedures and contracts for maintenance of both hardware and software used for scanning processes. Admissibility The Code of Practice for Legal Admissibility standard provides guidance for users of electronic documents in ensuring their document management procedures are most likely to meet requirements for acceptance as evidence in a court of law. Although compliance with the Code does not guarantee legal admissibility, it defines best practice. This document has referenced the standard where appropriate and the guidance herein summarises how this may be applied in general practice in Scotland. A Practice must, at any time and in a manner acceptable to a Court of Law, be able to demonstrate that the contents of a specific data file created or existing with a computer system has not changed since the time of storage and that where that data file is a digitised image of a physical original document, that the digitised image is a true facsimile of the original document. Authenticity Electronic images of original documents are treated as secondary evidence in a similar ways to photocopies. Information must be available regarding when the image was digitalised; the format used and the date of destruction of the original document. Comprehensive and complete No element of the original paper record should be excluded from the scanning process, although a notes process (as per 2.2.1.1 above) could be undertaken prior to ‘gardening’ back scanning to remove unnecessary paper from the record. Notes attached to any document must be included and practices need a process to handle this ensuring that all relevant information is captured and that the relationship between the note and the document that it is attached to is retained. Practices may wish to deal with any non clinical correspondence or notes separately from the clinical record and this may require it to be manually sorted. Recommended practice is to keep non-clinical documentation, for example legal and insurance reports, separate from the clinical record and that these documents should be clearly distinguished and separate from the patient’s clinical documents in the document management system.
This Management Policy must be able to demonstrate the integrity of the system either through inclusion of, or by linking to:- Details of acceptable and unacceptable file formats A security and access control policy; Standard operating processes and procedures including a system description manual (which would usually be supplied by the vendor) An auditing procedure and documentation of relevant outcomes to support the claim that the system is working normally. Similarly routine maintenance and replacement of worn parts of the scanning equipment is essential. Practices should have in place procedures and contracts for maintenance of both hardware and software used for scanning processes. Admissibility The Code of Practice for Legal Admissibility standard provides guidance for users of electronic documents in ensuring their document management procedures are most likely to meet requirements for acceptance as evidence in a court of law. Although compliance with the Code does not guarantee legal admissibility, it defines best practice. This document has referenced the standard where appropriate and the guidance herein summarises how this may be applied in general practice in Scotland. A Practice must, at any time and in a manner acceptable to a Court of Law, be able to demonstrate that the contents of a specific data file created or existing with a computer system has not changed since the time of storage and that where that data file is a digitised image of a physical original document, that the digitised image is a true facsimile of the original document. Authenticity Electronic images of original documents are treated as secondary evidence in a similar ways to photocopies. Information must be available regarding when the image was digitalised; the format used and the date of destruction of the original document. Comprehensive and complete No element of the original paper record should be excluded from the scanning process, although a notes ‘gardening’ process (as per 2.2.1.1 above) could be undertaken prior to back scanning to remove unnecessary paper from the record. Notes attached to any document must be included and practices need a process to handle this ensuring that all relevant information is captured and that the relationship between the note and the document that it is attached to is retained. Practices may wish to deal with any non clinical correspondence or notes separately from the clinical record and this may require it to be manually sorted. Recommended practice is to keep non-clinical documentation, for example legal and insurance reports, separate from the clinical record and that these documents should be clearly distinguished and separate from the patient’s clinical documents in the document management system.
SCIMP-Back-Scanning-Advice-for-General-Practices-Version-2-FINAL-18122013.docx