Policy No. Effective Date Last Reviewed Last Revised Next Review
M/YY M/YY M/YY M/YY
SCANNING and QC Policy Contents 1 2 3 4 5
Purpose ......................................................................................................... 2 Scope ............................................................................................................ 2 Definitions..................................................................................................... 2 Policy ............................................................................................................ 2 Responsibilities ............................................................................................. 3 5.1 Medical Records Clerk................................................................................3 5.2 Medical Records Department ....................................................................3 6 Procedures .................................................................................................... 3 6.1 Written Procedures ....................................................................................3 6.2 Performance/Quantity Standards ..............................................................3 6.3 Quality Indicators .......................................................................................4 6.4 Evaluation Rating Process ..........................................................................5 7 References .................................................................................................... 6 8 Policy Owner ................................................................................................. 7 9 Approval ....................................................................................................... 7 10 Revision History............................................................................................. 7
This policy is provided as a general guide for Piedmont Healthcare. It is not all encompassing and shall not be a substitute for the use of individual clinical judgment and training based upon the circumstances of each patient.
Page 1 of 7
POLICY Title
1
Policy No. Effective Date Last Reviewed Last Revised Next Review
M/YY M/YY M/YY M/YY
Purpose The purpose of this policy is to establish guidance for the correct scanning and quality control of paper charts being converted into the ImageNow Document Imaging System.
2
Scope This policy covers the Medical Records Department and student interns assigned to the Medical Records Department. It particularly applies to those Clerks performing scanning and QC functions.
3
Definitions Prep – Preparing paper charts for scanning including confirming correct patient name, MRN, CSN, account number, etc. Scanning – Scanning of loose paper charts into ImageNow Document Imaging System creating a single ImageNow document. Indexing – Assigning individual page(s) within an ImageNow document to appropriate Doc Types thereby creating an electronic chart organized by doc types. CSN – Contact Serial Number, the unique EPIC customer encounter number.
4
Policy It is the policy of Piedmont Healthcare that all inpatient, outpatient, surgery, emergency and observation encounters prepared for scanning and imaging into ImageNow meet designated quality and time standards. The Medical Records Department at Piedmont Healthcare is responsible for performing prep, scanning and QC functions on all pages scanned into the ImageNow document imaging system. These personnel are committed to: reviewing for correct patient information; ensuring readiness for scanning, scanning charts, and confirming image quality. These functions are performed on a daily basis according to an established priority schedule that assures the release of images into ImageNow within 24 hours of a patient encounter.
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POLICY Title
5
Responsibilities
5.1
Medical Records Clerk
Policy No. Effective Date Last Reviewed Last Revised Next Review
M/YY M/YY M/YY M/YY
Medical Records Clerk shall: 5.2
Generate Discharge reports. Prep charts for scanning. Scan charts. QC scanned charts. Work closely with Indexing function.
Medical Records Department Medical Records Department shall ensure that the paper charts of discharged patients be fully processed (prepped, scanned, QC and indexed) within 24 hours of a patient discharge.
6
Procedures
6.1
Written Procedures
6.2
Prep: For step-by-step procedures see procedure titled: Document prep Scanning: For step-by-step procedures see procedure titled: Scanning capture QC: For step-by-step procedure see procedure titled: Scanning QA
Performance/Quantity Standards 1
Based on AHIMA benchmark productivity standards, the following standards are proposed : Expectations per hour
Factors Affecting Production
Prep
340-500 pages
Tears, staples, lack of patient identification on each page, assembled or not
Scanning
1,200-2,400 pages
Speed of scanner; age of scanner; scanner maintenance; size of batches
QC
1,700 – 2,000 pages
Lack of attention to detail by the prepping and indexing staff; size of viewing screen
Scanning & QC
1600 pages
A combination of the two standards above.
Indexing
720-800 pages
Presence of bar codes on forms; presence of bar-coded patient labels
Page 3 of 7
POLICY Title
Policy No. Effective Date Last Reviewed Last Revised Next Review
M/YY M/YY M/YY M/YY
For the Prep function, count the number of pages in several one-inch thick stacks of documents, and then calculate the average number of pages in a one-inch thick stack of documents. Take the number of one-inch stacks processed in an hour and multiply by the average number of pages to determine the number of pages processed in an hour. For the Scan/QC and Indexing functions, the following reports need to be created from ImageNow or EPIC:
6.3
Number of pages scanned per day by employee, and by department.
Number of pages indexed per day by employee, and by department.
Quality Indicators Lack of the following indicators during a QC review will be assigned deduction points based on the following point charts.
Prepping (per inch of documents)
Deductions
Work Standard: Has performance standard been met? If NO = 4 points; if YES = 0 points Quality Indicators: Correct patient ID on all pages Labels on all pages All “like” documents placed together All “like” documents in chronological order Assembled in correct chart order Original poor quality documents marked Poor Source All 3rd party bar codes blacked out or covered All color pages pulled from chart and placed in single batch Patch code placed between charts Prep mechanics: repair pages, remove staples, remove edgings, remove NCR copies, etc.
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0 or 4.0
1.0 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1.0
POLICY Title
Policy No. Effective Date Last Reviewed Last Revised Next Review
Scanning & QC (Incoming workflow queue) Work Standard: Has performance standard been met? If NO = 4 points; if YES = 0 points Quality Indicators: All charts in batch scanned properly Correct patient ID on all pages All pages are in correct order with “like” doc types together All pages are legible All pages are oriented correctly Color images are of acceptable quality
Indexing
Deductions 0 or 4.0
1.0 1.0 1.0 1.0 1.0 1.0
Deductions
Work Standard: Has performance standard been met? If NO = 4 points; if YES = 0 points Quality Indicators: Correct patient CSN, MRN or name selected Correct document types assigned All patient data input/loaded into eForm Other 6.4
M/YY M/YY M/YY M/YY
0 or 4.0
2.0 2.0 1.5 0.5
Evaluation Rating Process Each month encounters from various patient types will be evaluated for prepping, scanning, QC and indexing accuracy. Patient types will include: IP, ER, OPS and HOD. A random selection of charts will be audited by the HIM Supervisor or designee based on established criteria. The final rating score will be calculated in the following manner: 1. The Quality Indicators Data Collection Forms will be completed for charts reviewed (Attachment A-C). 2. Results for quality indicators will be transferred to the Final Rating Score Calculation forms, steps 1-3 (Attachment D). 3. Results for the performance/quantity standard will be recorded on the Final Rating Score Calculation forms, step 4 (Attachment D).
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Policy No. Effective Date Last Reviewed Last Revised Next Review
POLICY Title
M/YY M/YY M/YY M/YY
4. The quality and quantity scores will be added together on the Final Rating Score Calculation forms, step 5 (Attachment D). 5. The total of deductions will be subtracted from 100 (step 6) to determine the final rating score. The results of the evaluation process will be discussed with each Medical Records Clerk. The standard Piedmont Performance policy will be utilized to initiate proper training and disciplinary actions. The following Rating Scale will be used to assess the overall prepping, scanning, and indexing quality for each Clerk. 99 to 100 96 to 98 90 to 96 Below 90
= Exceeds Expectations = Meets Expectations = Below Expectations = Unsatisfactory
The following chart will be used for annual evaluation purposes. Unacceptable
Needs Improvement
Fully Successful
Superior
Distinguished
1
2
3
4
5
Annual average rating score of below 90
Annual average rating score of 90-96
Annual average rating score of at least 97
Annual average rating score of at least 98
Annual average rating score of at least 99
7
References 1
Benchmarking Imaging: Making Every Image Count in Scanning Programs by Rose Dunn, RHIA, CPA, FACHE, FHFMA http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_034249.hcsp?dDocNam e=bok1_034249 Document Prep procedure, procedure # ____________ Scanning procedure, procedure # _____________ Scanning QC procedure, procedure # _____________ Standard Piedmont Performance policy
Page 6 of 7
POLICY Title
8
Policy No. Effective Date Last Reviewed Last Revised Next Review
M/YY M/YY M/YY M/YY
Policy Owner Senior Director HIM
9
Approval
Name, Title
Date
Name, Title
Date
A signed copy of this policy is maintained on file.
10
Revision History Date
Revision New policy.
Page 7 of 7
Attachment A
Quality Indicators Data Collection Form
Chart Prep Employee_______________________ Reviewer___________________ Date_______ 1. Encounter # ____________________ Circle Patient Type:
IP
ER
Possible 1.0 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1.0 0.5 6
Quality Indicator Correct patient ID on all pages Labels on all pages All “like” documents placed together All “like” documents in chronological order Assembled in correct chart order Original poor quality documents marked Poor Source All 3rd party bar codes blacked out or covered All color pages pulled from chart and placed in single batch Patch code placed between charts Prep mechanics: repair pages, remove staples, remove edgings, remove NCR copies, etc. Total
2. Encounter # ____________________ Circle Patient Type: IP Quality Indicator Correct patient ID on all pages Labels on all pages All “like” documents placed together All “like” documents in chronological order Assembled in correct chart order Original poor quality documents marked Poor Source All 3rd party bar codes blacked out or covered All color pages pulled from chart and placed in single batch Patch code placed between charts Prep mechanics: repair pages, remove staples, remove edgings, remove NCR copies, etc. Total
OPS HOD
ER
Actual
OPS HOD Possible 1.0 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1.0 0.5 6
Actual
Total for all encounters Average Note: Include any additional areas for improvement under the Other category. Examples of items to be captured are: No discharge date on IP face sheet No deceased stamp on face sheet Encounter numbers not on back of documents Labels covering signatures or information Documents in chart that should be discarded
Attachment B
Quality Indicators Data Collection Form
Scanning & QC Employee_______________________ Reviewer___________________ Date_______ 1. Encounter # ____________________ Circle Patient Type: IP
ER
Possible 1.0 1.0 1.0 1.0 1.0 0.5 0.5 6
Quality Indicator All charts in batch scanned properly Correct patient ID on all pages All pages are in correct order with “like” doc types together All pages are legible All pages are oriented correctly Color images are of acceptable quality Other Total
2. Encounter # ____________________ Circle Patient Type: IP
ER
Quality Indicator All charts in batch scanned properly Correct patient ID on all pages All pages are in correct order with “like” doc types together All pages are legible All pages are oriented correctly Color images are of acceptable quality Other Total
ER
Actual
OPS HOD Possible 1.0 1.0 1.0 1.0 1.0 0.5 0.5 6
Quality Indicator All charts in batch scanned properly Correct patient ID on all pages All pages are in correct order with “like” doc types together All pages are legible All pages are oriented correctly Color images are of acceptable quality Other Total
3. Encounter # ____________________ Circle Patient Type: IP
OPS HOD
Actual
OPS HOD Possible 1.0 1.0 1.0 1.0 1.0 0.5 0.5 6
Actual
Total for all encounters Average Note: Include any additional areas for improvement under the Other category. Examples include: No discharge date on IP face sheet No deceased stamp on face sheet Encounter numbers not on back of documents Labels covering signatures or information Documents in chart that should be discarded
Attachment C
Quality Indicators Data Collection Form
Indexing Employee_______________________ Reviewer___________________ Date_______ 1. Encounter # ____________________ Circle Patient Type: IP
ER
Possible 2.0 2.0 1.5 0.5 6
Quality Indicator Correct patient CSN, MRN or name selected Correct document types assigned All patient data input/loaded into eForm Other Total
2. Encounter # ____________________ Circle Patient Type: IP
ER
Quality Indicator Correct patient CSN, MRN or name selected Correct document types assigned All patient data input/loaded into eForm Other Total
ER
Actual
OPS HOD Possible 2.0 2.0 1.5 0.5 6
Quality Indicator Correct patient CSN, MRN or name selected Correct document types assigned All patient data input/loaded into eForm Other Total
3. Encounter # ____________________ Circle Patient Type: IP
OPS HOD
Actual
OPS HOD Possible 2.0 2.0 1.5 0.5 6
Actual
Total for all encounters Average Note: Include any additional areas for improvement under the Other category. Examples of items to be captured are: No discharge date on IP face sheet No deceased stamp on face sheet Encounter numbers not on back of documents Labels covering signatures or information Documents in chart that should be discarded
Attachment D
Final Rating Score Calculation Form Employee name:
Date:
Position:
Function:
1. Total quality indicator points for all encounters reviewed (see QC Data Collection forms). 2. Number of encounters reviewed 3. Average total quality indicator points (step 1 divided by step 2) 4. Were work standards met for this function during this review period?
Yes, 0 points No, 4 points
5. Total points (step 3 plus step 4, maximum value of 10) 6. Quantity and Quality (Q2) Rating Score (100 – step 5)
____________________________ (Employee Signature)
____________________________ (Supervisor/Manager Signature)
The following Rating Scale will be used to assess the combined quantity and quality score: 99 to 100 = Exceeds Expectations 96 to 98 = Meets Expectations 90 to 96 = Below Expectations Below 90 = Unsatisfactory
The following chart will be used for annual evaluation purposes. Unacceptable 1 Annual average rating score of below 90
Needs Improvement 2 Annual average rating score of 90-96
Fully Successful 3 Annual average rating score of at least 97
Superior 4 Annual average rating score of at least 98
Distinguished 5 Annual average rating score of at least 99
