This policy describes and defines the processes to be undertaken
when scanning documentation onto the Electronic Patient Record
(EPR) to ensure adherence to BIP 0008 Code of Practice for Legal
Admissibility and Evidential Weight of Information Stored
Electronically as per British Standard 10008:2014.
Key Words:
Scanning, Patient Document, Day Forward,
Clinical Documentation, Legal Admissibility,
Weight of Evidence, Electronic Records
Version:
4
Adopted by:
Trust Policy Committee
Date this version
was adopted:
24 February 2022
Name of Author:
Scanning Lead
Name of
responsible
Committee:
Data Privacy Committee
Please state if
there is a reason
for not publishing
on website:
N/A
Date issued for
publication:
February 2022
Review date:
July 2024
Expiry date:
1 February 2025
Target audience:
All staff who access, process and / or maintain
patient records
Type of Policy
Non Clinical
Which Relevant CQC
Fundamental Standards?
9 & 12
Clinical Document
Scanning Policy and
Procedure
Page 2 of 29
Contents
Version Control.....................................................................................................................4
Equality Statement................................................................................................................5
Due Regard............................................................................................................................6
Definitions that apply to this policy.....................................................................................6
1.0 Purpose of the Policy......................................................................................................7
2.0 Summary of the Policy……………………………………………………..…….………........7
3.0 Introduction………………………………………………………………..….…………….…...8
4.0 Duties within the Organisation......................................................................................9
5.0 Legal Admissibility………………………………………………………….………..…..……10
5.1 Retention of documentation……………… ………………………………….………..……11
5.2 Legal Implications……………………………………………………………………………...11
6.0 Technical Requirements……………………………………………………….……………..11
6.1 System Size Limitations………………………………………………………….….………..11
6.2 Use of OCR (Optical Character Recognition)……………….……………….….…..…....11
6.3 Colour Documents…………………………………………………………………..…….…..11
6.4 Duplicate Letters…………………………………………………………….……..…….….…11
6.5 Administrative Letters…………………………………………..……………….……...….…12
6.6 Indexing and Metadata…………………………………………………………………....…..12
6.7 Communication & Letters………………………………………………….……….……...…13
6.8 Record Attachments …………………………………………………………………….…….13
6.9 Compression……………………………………………………………………….…...…..…..13
6.10 Temporary storage of scanned and uploaded documents……..………………...….13
6.11 Scanning Timescales ………………………………………………………………………..13
7.0 Scanning and Quality assurance Processes…………………………………….………..14
7.1 Preparation to Scanning………………………………………………………….……...…...14
7.2 Scanning …………………….……………………………………………………………..…...15
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7.3 First Level Quality assurance………………………………………………………….…....16
7.4 Second Level Quality assurance………………………………………………………..…..16
7.5 External Level Quality assurance………………………………………………….…....…..17
7.6 Rescanning………………………………………………………………………….….…..…...18
7.7 Audit …………………………………………………………………………………..…..…..…18
8.0 Monitoring and reporting…………………………………………………………………......18
9.0 Retention………………………………………………………………………………….….…19
10.0 Risks……………………………………………………………………………………….…....19
11.0 Disaster Recovery/Business Continuity…………………………………………….…....19
12.0 Mental Health Act Documentation…………………………………………………..……..19
13.0 Working files……………………………………………………………………….….……....19
14.0 Art/Therapeutic records…………………………………………...……………..……........20
15.0 Copyright Materials……………………………………………….………………….………20
16.0 Training Needs…………………………………………………………….……….…...….....20
17.0 Communication……………………………………………………………………….......…..20
18.0 Monitoring Compliance and Effectiveness................................................................21
19.0 Standards/Performance Indicators.............................................................................22
20.0 References and Bibliography………………………………………...…………….…........22
Appendix 1 Clinical Document Scanning High Level process……….………...................23
Appendix 2 Sample Quality Assurance Log.…….…….………………………..…................24
Appendix 3 Training Requirements .................................................................................25
Appendix 4 NHS Constitution Checklist .........................................................................26
Appendix 5 Stakeholder and Consultation........................................................................27
Appendix 6 Due Regard Screening Template Statement ………………………..................28
Appendix 7 Data Privacy Impact Assessment...................................................................29
Page 4 of 29
Version Control and Summary of Changes
Version
number
Comments
(description change and amendments)
1.0
First draft As agreed by Document Scanning Project Board
1.0
Final Draft for approval
2.0
First revision – removal of procedures and updated with further BIP 0008
information following Stage 1 Audit in March 2019
3.0
First revision following successful accreditation to British Standard 10008:
2014:1 Legal Admissibility and Weight of Evidence of Information Stored
Electronically, amendments described below:
Page
Sectio
n
Description of change
n/a
n/a
Removal of reference to RiO throughout including any reference to RiO specific
functionality such as naming conventions.
Front
page
n/a
Addition of a key word
Name of responsible committee amended
5
n/a
Update to contact details
6
n/a
Added & slight rewording within definition table
7
1.0
Slight rewording of paragraph 2 & 3
7&8
2.0
Slight rewording of bullet point numbers 2, 6 & 8
8
3.0
Addition to the end of paragraph 4.
8
3.0
Slight amendment to Policy exclusions added
9
4.2
Paragraph 2 slight rewording to ‘they’
9
4.4
Changed from Head of Data Privacy
9
4.6
Addition to end of paragraph
9
4.7
Addition to end of paragraph
9
4.8
Addition of paragraph at end outlining line manager responsibility to manage and
escalate issues affecting compliance
9
4.9
Slight amendment
10
5.1
Amended to reflect Trust has achieve compliance and what action must be
taken for services not meeting compliance levels required
10
5.2.1,
6.1
Slight reword of paragraph 2
11
6.4
Section added to explain in further detail how duplicate correspondence should
be managed where the addressee is different and the correspondence refers to
multiple subjects
12
6.5
Addition of Clinical Letters to reflect use of SystmOne functionality
12
6.6
Slight rewording of paragraph 1
Slight rewording of bullet point 1
Removal of naming convention (RiO only)
Slight rewording of bullet point 3 & 4
12
6.9
New section for system migration.
13
6.11
Revision to scanning timescales
13
6.11
Slight rewording of paragraph 3.
14
7.0
Slight rewording to bullet points 2, 3, 4 & 5
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14
7.1
Bullet point 1
Addition to paragraph 2 to include training, scanner device cleaning measures,
slight expansion on the use of long paper setting.
Slight rewording & amendment to paragraph 4 to include criminal proceedings
and scanner profile tests performed with British Standard test targets (ISO
12653).
Bullet point 2
Addition to end of paragraph 1.
New paragraph added to include safe transportation of documents for scanning;
managing items stuck to documents for scanning such as post-it notes;
separation and slight expansion for managing documents such as photocopies
and document size etc.
14-18
7.0-7.7
Reordering and slight rewording of section
Inclusion of non-conformity process
Addition of incident being recorded for non-return / non action of errors
Addition of expectation for service to check whole batch if 50%+ level of errors
found within internal check
Addition of paragraph to explain further sample checking buy Quality Assurance
team where 50%+ error level found
Addition of internal audit
Addition of monitoring
19
8.0
Slight rewording.
20
17.0
Section added for Communication.
21
18.0
Addition to monitoring to include action for error level over 10%, non- conformity
log ,equipment maintenance, SOP competence, internal QA checking, late
submissions, escalation of errors not corrected, reportable incidents where
documents are missing, on the wrong record or where error documents are not
corrected and returned within 4 weeks, ceasing of checking where errors
increase ≥10%.
22
19.0
Addition of 100% training in EPR & 10008
Appendices
Removal of appendices 1,3 – all process flow charts are available in the SOP,
only the high level process and scan log example is included in the Policy –
Appendix 1 &2.
Version 4.0
Reviewed with minor amendments to include the overarching Clinical Document
Scanning Standard Operating Procedure now in use.
For further information contact:
The LPT Clinical Document Scanning Project Team via [email protected] .
Equality Statement
Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that
meet the diverse needs of our service, population and workforce, ensuring that none are placed
at a disadvantage over others.
It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for
all.
This document has been assessed to ensure that no one receives less favourable treatment on
the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual
orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity.
In carrying out its functions, LPT must have due regard to the different needs of different
protected equality groups in their area.
This applies to all the activities for which LPT is responsible, including policy development and
review.
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Due Regard
LPT must have due regard to the aims of eliminating discrimination and promoting equality when
policies are being developed. Information about due regard can be found on the Equality page on
e-source and/or by contacting the LPT Equalities Team.
Definitions that apply to this Policy
Batch
A set of paper documents that have been scanned onto the patient
electronic record with a usual maximum size of a week’s worth of scanned
documentation
Day Forward
Documentation created or received from a specific date onwards.
DPI
Dots Per Inch, a measure of resolution.
Electronic Storage
Storage medium or device used by an information management system to
store information.
EPR (Electronic
Patient Record)
In the Trust this refers to SystmOne. Some patients may have records in
multiple SystmOne units concurrently.
Exception
An exclusion from the usual expected process
Expungement
The process of deleting a document from the system where no evidence of
the document ever having been on the system is available
Legal Admissibility
Evidence to demonstrate that the scanned version is a true representation
of the original.
Metadata
Information regarding document structure and properties such as the
document type and size. Data regarding data.
Non Conformity
A failure in the usual conformity of the process
OCR Optical
Character
Recognition
Software technology that recognises text within documents in order to
search a database for data entry purposes
Original Document
Document from which a copy is made or from which an image is captured.
Original – definition does not mean necessarily original document as we
may have a copy of a document it means the original, paper version
Page
Single image entity, such as one side of a sheet of paper, a drawing or plan
Record
Information created, received and maintained as evidence and information
Resolution
Ability of a scanner or image generation device to reproduce the details of
an image
Scanner
Device used to capture data of a copied image into a digital file format, e.g.
PDF
Scanning
The process that converts the image of a document into a digital form, by
detecting the amount of light reflected from elements of a document into a
form that is suitable for retrieval, processing and communication by digital
computer
System
In this Policy, this always means the Electronic Patient Record (EPR)
TWAIN
A software driver to enable scanned image direct into other applications i.e.
within an EPR such as SystmOne.
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1.0. Purpose of the Policy
Although the Record Keeping and Care Planning Policy provides the overarching framework for
achieving high quality safe record keeping, it is based on the principle that the primary clinical
record is now held in an electronic format which brings many benefits to the care of the patient.
The Trust has had a phased implementation of Electronic Patient Records (EPR) with access to
trained, authorised staff only. Paper based records are outdated, impractical, unsecure and
becoming redundant in the digital era; the rise of EPR and the rise in costs keeping paper for its
retention schedule have led to the decision to scan the paper version as an equivalent digital
record and destroy. The Trust (LPT) is committed to the use of electronic document storage
which has many clinical and financial advantages over paper storage, including ease of access
and retrieval and reduction in off-site storage costs. LPT stores documentation received and
created outside of the patient EPR onto the patient’s relevant electronic patient record. LPT does
not use any other stand-alone electronic repository for the storage of patient records to ensure
clinical safety.
The Policy provides assurance to the Trust that where paper based patient records are
reproduced into an electronic version, the legal admissibility and evidential weight will not be
affected by the scanning process, by ensuring that staff undertaking the task of scanning check
the quality of every scanned image ensuring that authorised scanning capable equipment and
defined settings are used. The policy provides guidance to ensure the authenticity, integrity and
legal admissibility of scanned information as per the British Standard 10008:2014 requirements
for BIP 0008-1 Code of Practice Legal Admissibility and Evidential Weight of Information Stored
Electronically.
This Policy is Trust wide and must be adopted with the Standard Operating Procedure (SOP).
The SOP will detail all processes required. This Policy defines the system of processes to be
adhered to when scanning clinical documentation onto the EPR. The Trust has one EPR in use
in scope of this policy and this policy should be reviewed with the Record Keeping and Care
Planning Policy, Information Security Policies and Information Lifecycle and Records
Management Policy.
2.0. Summary and Key Points
The aim of this policy is to ensure that the following objectives are met:
Records are available when needed – all documentation received or created by the
service must be scanned and uploaded in line with the Trust’s Record Keeping Policy.
Similarly any emails or electronic information such as electronic referrals should be
uploaded within the same time frame;
Records can be accessed – all information is readily available and readable for those
clinicians who need to access it for patient care;
Records can be interpreted – the context of the record can be interpreted: who created
or added to the record and when, during which business process, and how the record is
related to other records;
Records can be trusted – the record reliably represents the information that was actually
used in, or created by, the business process, and its integrity and authenticity can be
demonstrated;
Page 8 of 29
Records can be maintained through time – the qualities of availability, accessibility,
interpretation and trustworthiness can be maintained for as long as the record is needed,
perhaps permanently, despite changes of format;
Records are secure – from unauthorised or inadvertent access, alteration or erasure, that
access and disclosure are properly controlled and audit trails will track all use and
changes. To ensure that records are protected and held in a robust format which remains
readable for as long as records are required;
Records are retained and disposed of appropriately – using consistent and
documented retention and disposal procedures, which include provision for appraisal and
the permanent preservation of records with archival value; and
Staff are trained – so that all staff are made aware of their responsibilities for record-
keeping and record management processes described in this policy and under statute:
The General Data Protection Regulation and Data Protection Act 2018;
Staff understand that it is their responsibility to scan in accordance with this policy
and how to escalate any issues and the implications and ramifications of non-conformity,
which may be dealt with under the Disciplinary Policy and Procedure;
Staff understand that it is their responsibility to check every document that is
scanned and to use a scanner which is authorised for such purposes.
Within LPT, the task of scanning onto clinical records will be undertaken within each relevant
clinical service providing care for the patient. The scanned documentation will be submitted to
the Clinical Document Scanning Quality Assurance Team for independent Quality Assurance
checking as defined within this policy. The objectives will be measured via the production of
figures presented in monthly reports as described in section 7.9 Reporting on an ongoing basis.
The Clinical Document Scanning Team manage the scanning system processes, however,
assistance for technical support with IT equipment/hardware and software (including the EPR)
should be sought from the Leicestershire Health Informatics Service (LHIS) through the Service
Desk.
3.0. Introduction
Where scanning is used the main consideration is that the information can perform the same
function as the paper counterpart did and, like any evidence, scanned records can be challenged
in a Court. This is unlikely to be a problem provided it can be demonstrated that the scan is an
authentic record and there are technical and organisational means to ensure the scanned
records maintain their integrity, authenticity and usability as records, for the duration of the
relevant retention period.
If this is a record type which must or may be selected and transferred to a place of deposit, the
place of deposit should be asked whether they wish to preserve the hard copy and/or the scans.
If the hard copy is retained, this will constitute ‘best available evidence’ for legal purposes, rather
than the scanned copy.
The legal admissibility of scanned records, as with any digital information, is determined by how it
can be shown that it is an authentic record. An indication of how the Courts will interpret evidence
can be found in the civil procedure rules and the Court will decide if a record, either paper of
electronic, can be admissible as evidence.
The standard, ‘British Standard 10008 Electronic Information Management - Ensuring the
authenticity and integrity of electronic information’, specifies the method of ensuring that
electronic information remains authentic. The standard deals with both ‘born digital’ and scanned
records.
1
This Policy refers to scanned records under British Standard 10008:2014 – BIP 0008-1.
1
IGA Records Management Code of Practice for Health and Social Care 2016
Page 9 of 29
This policy applies to ‘day-forward’ scanning only and does not refer to the scanning of historical
records or corporate records. Under this policy, all information relating to the care of a service
user, received or created outside the EPR, is required to be scanned in order to be added to the
EPR across all clinical services in the Trust.
Exclusions from this policy are:
Complaints from service users
Patient Advice Liaison Services
LPT Incident report documentation
Corporate services
Police National Computer (PNC) outputs
Medical Records from other organisations
As this information should not be uploaded to the patient healthcare record.
This Policy applies to the scanning of paper based information onto the clinical record; it does not
apply to the electronic transfer of information.
4.0. Duties within the Organisation
The Trust Board has a legal responsibility for Trust policies and for ensuring that they are
carried out effectively.
Trust Board Sub-committees have the responsibility for ratifying policies and protocols.
4.1 Chief Executive
The Chief Executive has overall responsibility for Information Governance within the Trust.
4.2 Caldicott Guardian
The Trust Caldicott Guardian is the Medical Director. They hold the responsibility for
safeguarding the confidentiality of patient information and will oversee the arrangements for the
use and sharing of patient information.
4.3 Senior Information Risk Owner (SIRO)
The Trust SIRO has responsibility for coordinating the development and maintenance of
information risk management policies, procedures and standards for the Trust.
4.4 Data Protection Officer
The Data Protection Officer has responsibility for ensuring policies are in place for the protection
of staff, patient and sensitive organisational information.
4.5 Document Scanning Change Lead
The Document Scanning Change Lead has a responsibility to ensure that the all relevant
scanning activities within the Trust comply with British Standard 10008:2014 and any other
appropriate legislation, through the provision of policy, guidance and instruction to staff who scan
clinical documentation and provide advice where required and manage any external audits.
4.6 Divisional Directors and Heads of Service
Divisional Directors and Heads of Service are responsible for ensuring that appropriate standard
operating procedures are in place to support and ensure that the scanning of information within
their responsible areas are undertaken in line with this policy to ensure the Trust retains
compliance with British Standard 10008:2014.
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4.7 Senior Managers
Senior managers are responsible for ensuring that this policy and any supporting policies,
standard operating procedures and guidelines are built into local processes and ensure
maintenance of compliance to ensure the Trust retains compliance with British Standard
10008:2014.
4.8 Line Managers
Line Managers are responsible for ensuring that all staff involved in the scanning of clinical
documentation are fully aware of this policy and their individual responsibilities. Managers must
ensure that staff have undertaken appropriate training to gain access to the EPRs. Managers
must ensure that the staff they are responsible for, who are required to scan clinical documents
as part of their role, undertake the Clinical Document Scanning Training and pass the
assessment before they scan onto a patient record. Managers must ensure the standard
operating procedures are followed in line with this policy and the training competency is
completed and signed off. Line managers ensure access to the EPR is only granted via
Smartcard technology, by an approved Registration Authority Sponsor, once training for the
relevant system has been completed. No access is granted prior to training, this ensures that
electronic identity can be applied to a document’s addition to the EPR. It is line managers’
responsibility to ensure that the staff member is competent in both use of the EPR and Clinical
Document Scanning. Line managers are responsible for ensuring that their services are
achieving the required action and any subsequent measures required such as escalation of
issues to senior managers, the retraining of staff etc. Line managers are responsible for local
process risk assessments with support from the Clinical Document Scanning Team to ensure the
Trust retains compliance with British Standard 10008:2014. Following scanning training (LHIS &
Theory on ULearn staff must be signed off and deemed competent locally with local scanning).
4.9 Staff (including Students on placement)
All staff, whether permanent, temporary or contracted, who scan clinical information into patient
records should be fully aware of their roles and responsibilities for the secure scanning of clinical
information and for ensuring that they comply with these on a day-to-day basis. They are
required to complete the Clinical Document Scanning Training via U-Learn and pass the
assessment before scanning onto a patient record to ensure the Trust retains compliance with
British Standard 10008:2014.
5.0 Legal admissibility
Legal admissibility is a core Records Management principle and if a document is scanned it must
be a true representation of the original.
Proving the authenticity of a scanned document is crucial if required as evidence in Court and
that any document scanned into or uploaded has not been changed since the time of its storage.
For example, a referral letter received by post which is scanned and uploaded to the EPR via a
folder on the network is a true representation of the original providing the appropriate processes
and quality measures were undertaken when creating the scanned image.
The organisation has a duty to ensure documents created or scanned, stored and migrated
through electronic systems meet the evidential weight as outlined in the Civil Evidence Act 1995
to ensure Legal Admissibility should a Court require it.
Compliance with this procedure does not guarantee legal admissibility. It is possible to maximise
the evidential weight of a record/ document by setting up authorised procedures and being able
to demonstrate in Court that those procedures have been followed, to ensure the best possible
evidence can be produced in case of Court proceedings.
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5.1 Retention of original documentation
Services that do not meet the requirements of British Standard 10008:2014 will be required to
ensure their paper copies are retained for respective retention periods; services adhering to
British Standard 10008:2014 and meeting Trust objectives will have their paper copies securely
destroyed following a short retention period (unless exemption from destruction applies refer to
section 7.11).
5.2 Legal Implications
The main risk to the Trust, if scanning is undertaken without consideration and
implementation of this policy and its requirements, is that the Trust will not be able to prove the
integrity of the EPR and that all EPRs may be dismissed as hearsay and therefore not be used
as evidence within a Court of Law, Tribunal or Case Review.
The Trust will be required to produce authenticated outputs from the EPR where records are
requested and the paper copies have been destroyed.
6.0 Technical requirements
6.1 System size limitations
Documents fewer than 5 MB in size in scanned format can be uploaded as one document to the
EPR (SystmOne). There may be a short delay in some EPRs when retrieving documents greater
than 1.5 MB in size.
Where one document breaches the system size limitation for upload, it is permissible to scan and
upload the record in defined sequential parts ensuring the format Page X of Y is used e.g., Part 1
of 3, Part 2 of 3 etc.
6.2 Use of OCR (Optical Character Recognition) software
OCR technology may be installed and enabled within the EPR for certain functions within the
system however, due to accuracy concerns and associated risks, the Trust does not allow the
use of OCR technology within patient records including when uploading documents.
6.3 Colour Documents
The following documents must be scanned in colour:
Psychiatric Observations / ECG’s / Prescription cards / DNR sheet / Track & Trigger /
NEWS
This list is not exhaustive; please refer to the local SOP or request a clinical decision if required.
Copies of prescriptions do not need to be in colour.
6.4 Duplicate letters
Where duplicate letters e.g., carbon copy letters to different MDT members, are being added to
the patient record, either on a single record or shared records, please refer to the services
operational process for managing this. Letters addressed to different clinicians (even where the
letter content is the same) are not duplicate letters and should be uploaded to the patient record.
Documents that have not been scanned should not be submitted for QA check.
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Where duplicate letters are for multiple patients i.e., siblings, the relevant number of copies
should be taken then the patient NHS numbers and name as minimum 3 items added to each
relevant document and uploaded to the correct record. Information should not be obscured as
per record keeping standards.
6.5 Letters
Administrative Letters
Letters of this nature, which do not require a clinical signature (or electronic audit) i.e., an
appointment letter, must be created via the EPR and directly saved back into the EPR by the
administrative author.
Clinical Letters
Letters of this nature, which do require a clinical signature (or electronic audit) i.e., an
assessment letter, these can be drafted by administrative staff and saved as a draft, the clinician
can then review and save as final within the EPR.
6.6 Indexing and Metadata
An electronic documents’ metadata may contain information about how long the document is,
who the author is and when the document was created. Metadata is held in the background of
the system and therefore may not be visible to front end users of the system. Some metadata is
entered by the user onto the system at the point of adding the document to the patient record,
such as:
Document type
Pre-defined pick lists of available options are contained within the EPR and the user must select
a document type when adding the scanned image to the patient record. Document types are
clinically agreed prior to adding to the live EPR.
Document date
Appropriate document dates must be entered when the document is uploaded by selecting the
appropriate date from the EPR system’s calendar. The date may vary according to the content
and nature of the document. The following should be observed:
Document contains clinical intervention date e.g., an Outpatient letter from another hospital:
the date of the clinical intervention is to be used
If there is no clinical intervention date i.e.,’ This patient was reviewed recently’ then the date
of the letter/document is to be used.
If there is neither then the date stamp received or created by the Trust will be used.
If there is no clinical event i.e., an appointment letter, this is to be dated the date of the
letter. Future dates cannot be entered into the EPR.
Service exceptions must be raised with the Clinical Document Scanning Team.
Document Author
This must be entered as the author of the document. If this is external and is not known, then
‘unknown’ must be entered. Where there are multiple authors i.e., observation forms completed
within an inpatient environment, the name of the ward / home must be used.
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SystmOne has 2 areas to store items that may not have been created within the EPR:
Communications & Letters and Record Attachments. The following guide must be observed:
6.7 Communications & Letters
This is to be used to store correspondence and documents.
6.8 Record Attachments
This is to be used to add other file types to the patient record, such as images and medical
device output files.
6.9 System Migration
Where EPRs are transferred or replaced, or a legacy system is introduced, steps must be taken
to ensure that the original metadata is protected and not altered in any way to ensure digital
preservation. System upgrade User Acceptance Testing (UAT) must include any implications to
the storage of scanned documentation. A risk assessment must be completed to ensure all risks
are documented and controlled.
6.9 Compression
Compression settings should only be used where there is no loss of information to the scanned
version of the document, i.e., lossless compression, which does not remove any aspect of the
image. LPT does not use any compression settings other than what is already defined in the
scanner profiles to avoid any loss of document / information integrity / outside acceptable limits
6.10 Temporary storage of scanned or uploaded documents
Where the document cannot be scanned straight to the EPR (Non-TWAIN complaint) i.e., where
the document is too large for a desktop scanner to be scanned using TWAIN driver), a folder
must be created within the department/service’s network Drive folder; this will be used to
temporarily store the scanned documents. If one of the Trust’s Multi-Function Devices (MFD) is
used, these are defaulted to scan to the email address associated with the staff member’s
Managed Print Service (MPS) badge or can be set to scan to a secure folder
Once the document has been uploaded the scanned image must be removed from the
drive/scanner or email account that the scan was sent to. Staff must not retain any scanned
image once it has been successfully uploaded, this will reduce the risk of duplication and ensure
start to finish completion of the process. The scanned document must be uploaded to the service
user’s health care record as soon as is practicably possible after it has been scanned.
These topics are covered in the Clinical Document Scanning Training which is mandatory for staff
required to scan onto healthcare records as part of their role.
6.11 Scanning Timescales
Scanning of clinical documentation should occur within clinically risk-based timescales that will be
agreed and implemented locally. Complete documents should be scanned onto patient records
unless clinical need necessitates partial documents to be scanned.
Depot / medication cards should be scanned once the card is complete, medication is changed/
discontinued, or the patient is discharged; whichever is sooner.
DNAR (Do Not Attempt Resuscitation) forms should be scanned upon patient discharge, with a
photocopy of the original form forwarded to the Quality assurance Team, as the original must
accompany the patient to their onward destination.
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7.0 Scanning and Quality assurance Processes
The processes required to comply with British Standard 10008 will include the following stages:
Preparation to Scan (including training)
Scanning
First Level Internal Quality assurance – Quality Control
Second Level Internal service Quality Assurance Checks
External Quality Assurance Checks
Rescanning
Audit
Flowcharts for each process can be found within the SOP.
7.1 Preparation to Scan
Once staff members are trained in the EPR & associated scanning functionality, have
successfully completed, and passed the U Learn training session for Clinical Document Scanning
and have completed the SOP Competency, scanning can commence.
Scanning equipment
Only Trust approved scanning equipment must be used. Staff will have access to a desktop
scanner or Multi-Function Device (MFD). The use of the LPT scanning profiles is mandated for
desktop scanners, other scanning devices e.g., Multi-Function Devices (MFDs) scanning
guidance must be followed.
Scanning equipment must be regularly cleaned, maintained, and tested as per service
agreements and any issues must be reported to the LHIS Service Desk. Desktop scanners
should be cleaned monthly by users or as required according to the manufacturer specification
and cleaning records should be maintained. Cleaning guidance can be obtained from the Clinical
Document Scanning Team. MFDs will be maintained in line with SLA’s.
The procurement of scanners must always be completed via the Trust’s ordering process.
Only Trust approved scanning profiles must be used, as they enable documents to be scanned
and stored in an unchangeable format, users’ software does not allow changes to be made to
document once it has been scanned. Staff found using software to edit scanned documents will
be subject to action under the Trust Performance policy and relevant information security policies
and statue where relevant for criminal proceedings. The Trust scanning profiles have been
tested with test targets from British Standard ISO 12653 to evaluate the quality of outputs from
the scanner.
The relevant SystmOne gateway must be in use within the relevant unit being scanned onto the
on the local network that the scanning is being undertaken from.
Page 15 of 29
Document Preparation
Staff must ensure that each page for scanning is examined and properly prepared as described
in the Preparation of Documents Prior to Scanning flowchart in appendix 1 to ensure that as
high a quality image as possible is obtained. Staff must follow standards to include the following
information as a minimum: DOB, Patient name and NHS number. The Staff member must
check the document before adding to the patient record on the EPR; this is the stage that the
scanning operative assures that the scanned documents are a true, accurate and complete
copy of the original.
Staff must ensure that prior to scanning; documents are transported safely and securely by
using appropriate methods i.e., a box file to minimise the risk to the original document’s
integrity. Any documents presented for scanning with temporary notes (such as a Post It note)
must be returned to the clinician for removal. It is not appropriate to scan documents with such
items attached. Where this is not possible, the document should be photocopied (using the
flatbed) and scanned, then the temporary note removed, and the document scanned without the
post it note. The temporary note should be re-attached to the document for submitting to the
Clinical Document Scanning Quality Assurance Team.
Documents that are photocopied prior to scanning i.e., the patient has taken the original after it
was scanned and we have retained the copy; the photocopy must be marked ‘copy’ to indicate
that the scan is a scanned photocopy of the ‘original’ version.
Documents must be scanned at their original size e.g. A4, A3 etc. Long paper such as ECG
traces can be scanned via the desktop scanners, please seek support from the LHIS Service
Desk if required to ensure that the ‘long paper’ setting is enabled on applicable scanners.
7.2 Scanning
Staff must ensure they check every scanned image of the original document once they have
scanned it onto the service user’s record. Staff must use a Trust approved scanning device set
to an authorised profile.
Non-Conformity
Where the scanning process is interrupted or cannot be completed for example, a document is
removed from the batch after it has been scanned as a clinician requests the document before it
is sent for QA or a technical issue arises part way through scanning; a non-conformity log (with
rationale) must be completed and attached to the relevant documents and submitted separate
from the batch to ensure compliance with British Standard 10008:2014.
Exception reporting
Where a good quality scan cannot be achieved following 3 attempts using the defined guidance
(if for example, the original is of a very poor quality), an exception report must be sent with the
document to the Quality Assurance Team separate from the weekly batch. These documents will
not be counted as part of any batch. This is to ensure that these are logged and risk assessed for
any acceptable limits of information loss or retained. Documents that are not accepted as an
exception will be returned to the service for rescanning as appropriate.
Submission of batches
o Weekly batches of original scanned documentation must sent to the Quality assurance
Team within double envelopes/tamper proof envelopes / approved secured and
tagged transportation crate, labelled with the service name, relevant SystmOne unit
name and scanned date range of documents. A tracking transit form must be used
and this will provide a receipt from the collecting porter. Empty boxes (where in use)
will be returned to the services once they have been processed.
o Batches of scanned documents sent later than 2 weeks must be submitted with a
100% internal quality check. Batches received after this time affect local error
correction rates and can affect the Trust adherence to British Standard 10008:2014.
Page 16 of 29
o Do not mix batches of uploaded documents to different SystmOne units or mix/add to
documentation returned for re-checking with fresh batches.
Scanning Guidance
A simple guidance procedure flow chart can be found at Appendix 1. This may be laminated
and used as an aide memoire to assist when scanning/uploading documents. Further guides
are available on the Intranet and within the SOP
7.3 First Level Internal Quality Assurance
Staff must ensure that once a document has been scanned:
The document has been uploaded to the correct patient record
The same number of pages has been scanned and all are the correct orientation to the
original (please note, the orientation of blank pages does not matter).
All pages are legible
The clinical intervention date is entered as the document date, not the date the document
is scanned
Documents must not be scanned with items such as Post It notes in situ
The scan is an exact replica of the original paper document
All documents must be scanned straight and the whole of the document needs to be
visible, with nothing missing or covered / obscured on the scanned document.
Both sides of a page must be included even if the second side of the document is blank –
blank pages / sides must not be deleted.
Documents must be scanned in colour where coloured text, marks or diagrams made on
documentation provide a record of clinical care to the patient or holds clinical worth
(includes documents on coloured paper).
This list is not exhaustive - further reasons that a document will fail the quality assurance
process can be found within the SOP.
Once a document is scanned it should not be reprinted for clinical purposes, with the exception
of outside agencies / transfer to other Trusts or a Subject Access Request.
7.4 Second Level Quality Assurance Checks
Services must carry out an internal quality check on a random sample of batched documents
against their scanned images on the EPR
Internal service Quality Assurance Checks are a valuable tool in ensuring the service adheres to
processes described in this policy and issues are identified and rectified service level. It also
allows team and service level performance monitoring. Managers or peers will perform Quality
Assurance checks for 5 – 20% of batches according to service performance. This will be
increased where high error rates are prevalent. This should occur before the batch is sent to the
central Quality assurance Team for checking in line with British Standard 10008:2014 compliance
The Staff member performing the internal Quality Assurance Checks will select a random sample
of the batch and check the paper version against the scanned image. If the image does not
match the paper version then the internal Quality Assurance log must be completed as per the
process (available in the SOP) and the document must be removed and rescanned where
applicable. If errors over 50% are discovered within the local Quality Assurance check, the whole
batch must be checked within the service.
Supplementary training is available for staff undertaking Internal Audit Checks on request from
the Clinical Document Scanning Team. The documents selected for an internal check must be
separated from the rest of the batch and clipped to the log sheet then placed on top of the rest of
the batch being submitted.
Page 17 of 29
7.5 External Quality assurance check
The Clinical Document Scanning Quality Assurance Team will carry out authorised checking
processes on the batches of scanned original documents received before either retaining the
documents in line with the relevant records retention schedule or until secure destruction can be
undertaken.
The Quality Assurance team have ‘read only’ access to the EPR; this is the required level of
access for the role as the team do not make amendments to the patient record. The Quality
Assurance team assess the scanned quality by viewing the uploaded document on the EPR
against the original or copy (where indicated) paper version.
The quality assurance check describes the processes, controls and records that the service
will put in place to provide assurance that the quality assurance processes are sufficient to
successfully catch and therefore remove scanning defects. This does not check
documentation for clinical completeness. This will be undertaken by the Clinical Document
Scanning Quality Assurance team to assure confidence in the quality control process and to
ensure that all pages are legible, the same amount of pages have been scanned and they are
exact replicas of the originals. The amount of scanned documentation selected for Quality
Assurance checks will be calculated on a risk-based approach and will vary according to
performance. The second level checks will be stepped up as required in consultation with
service leads. Random increases will also be initiated.
The Quality Assurance check will also ensure the correct document category is used when
saving the document to the patient record to ensure swift clinical retrieval upon review of the
patient record.
The Quality Assurance check will be viewed on the EPR under normal viewing conditions as
per the technical specification installed by the Leicestershire Health Informatics Service.
The Quality Assurance team index all batches received into the team to ensure appropriate
tracking of clinical documentation.
Where a 50% or greater error rate is found within the sample being checked, a further sample
will be taken for checking. Where this further check results in another 50% or greater error
rate; the whole batch will be returned to the service with the error log for correction and
internal check of the batch remainder. This must then be resubmitted with an internal quality
assurance check for the batch remainder.
All new services submitting documentation to the Clinical Document Scanning Quality Assurance
Team will commence at 100% second level checking with reductions following satisfactory audit
of check results over an initial 4 week period. The check involves a minimum sample of 20% of
the batch up to a maximum of 100%, with a mid-way reduction to 50%. Any services not
meeting the requirement maximum error correction rate of 10% and below will not form part of
the Second level Quality Control checking process until this rate can be achieved.
Second level quality control checks should be undertaken and returned for re-scan or
archived within one month. Where this cannot be achieved, services will be informed.
Training will be provided for staff that perform second level Quality assurance.
Quality control sheets are completed for every checked batch and must be retained for
audit purposes (see appendix 2)
Documentation that does not meet the Quality standards will be returned securely to the
service via the portering service, which is tracked with a Quality Assurance control sheet
which details the error(s).
Errors that are not rectified after the second return will be raised with the Clinical
Document Scanning manager for further review to be raised with the team / services’
manager where applicable.
Page 18 of 29
Documentation that has been uploaded in error / to the wrong record will require removal
and adding to the correct record where applicable. An incident will be opened for these
occasions.
The sample size of checks performed will be from a risk based approach.
Returns that remain outstanding after four weeks will result in an incident being opened
and the batch remainder will be archived without the outstanding error documents.
7.6 Rescanning
Where the scanned image does not meet the requirements the service must correct the error
which may include re scanning the document, taking appropriate action to avoid the issue from
reoccurring. Staff undertaking scanning must ensure that the results meet Quality Assurance
requirements. Only staff with the appropriate access can remove a document from the system;
for SystmOne this is ‘marked in error’ but the document remains accessible within the deleted
items node, which staff with an enhanced access role can access. Changes made to documents
after upload are held within the audit trail within the EPR. Examples of the types of issues that
would result in a rejection during Quality Assurance checks can be found within the SOP.
The original document and the completed, signed scanning error log sheet must be returned
signed to the Quality Assurance team once rescanning is complete and the error has been
removed / rectified.
The batch must not be added to once it has been processed for the first time by the Scanning
Quality Assurance Team. If any documents are removed from the batch i.e. as they should not
have been added to the patient record, this must be indicated in the appropriate column on the
scan log sheet to account for the variation in the batch number once it is returned to the Scanning
Quality Assurance Team. Staff members must ensure that the Scan Error log sheet is
appropriately completed and signed to comply with audit requirements.
7.7 Audit
Internal
The identity of the staff member who was logged onto the system when the document was
scanned is held within the EPR within the system audit. The service will need to provide
assurance that appropriate procedures are in place to provide evidence that a scanned image is
an accurate and unchanged copy of the original and therefore maintains its integrity.
Internal audit of quality assurance checks performed by the Clinical Document Scanning Quality
Assurance team occur monthly to ensure that processes as described by this Policy are adhered
to within the team.
The procedure and processes will be audited annually to ensure that procedures are being
observed as per the requirements of British Standard 10008:2014. These audits will be
undertaken by the Clinical Document Scanning Team and reviewed by the Head of Service.
External
External audit undertaken by the British Standards Institute (BSI) will occur within selected
services to ensure the Trust retains certification under British Standard 10008:2014.
8.0 Monitoring and reporting
Team level error correction figures will be provided on a monthly basis to relevant managers and
performance charts will be provided at Trust Level. Services are expected to provide assurance
Page 19 of 29
for the management of their relevant correction errors. Areas of non-compliance will be
investigated to uncover the cause of any issues. Managers are expected to take the appropriate
action under the Trusts Performance & Conduct policy where these issues prevail as a direct
causation of the scanning errors and staff are accountable for this. Errors made within the
Clinical Document Scanning Quality Assurance Team will be provided on a 6 monthly basis.
Data for any incidents opened by the Clinical Document Scanning Team will be provided to
relevant managers / meetings on a quarterly basis.
9.0 Retention
All original documentation will be retained and archived in date boxes once quality control checks
have taken place until destruction (exclusions to destruction are documents relating to
Huntingdon’s or other archival value, research consent forms that must be retained by R&D team
or where litigation is suspected or any other documentation that the Trust deems appropriate to
retain). All destruction is based on risk assessment.
10.0 Risks
A Risk Log describing all relevant risks and the required action will be held on the Clinical
Document Scanning intranet page. Risks will be recorded on the Trusts’ risk management
software, Ulysses, as appropriate. Local services will undertake regular local process risk
assessments and share these with the Clinical Document Scanning Team.
11.0 Disaster Recovery / Business Continuity
If the EPR is unavailable then the service must follow their local Disaster Recovery Plan. Any
documents created during the system being unavailable must be added to the patient record as
soon as is practically possible following system reestablishment.
If clinical entries cannot be made within timescales then an incident report must be completed.
This may mean the retention of some patient documentation on site e.g. Emergency Grab
sheets, patient demographics as indicated by the services emergency plan. These can be held
securely in red temporary file folders.
12.0 Mental Health Act Documentation
The existing processes for Mental Health Act related paperwork must be continued. MHA
paperwork must not be sent to the central Quality assurance Team.
13.0 Working files
Any assessments that may take more than one clinical contact to complete may be securely
fastened and stored in individual labelled red temporary files, until the document is complete and
can be scanned in entirely. It is expected that as a minimum, a clinical entry will be made within
the EPR which will reference the assessment being undertaken / a summary of the appointment /
scan in the partially completed assessment if it is of clinical value to the patient / other clinicians
at that point – as per clinical judgement. Once completed the red files can be de-badged and re
used for another patient.
Page 20 of 29
14.0 Art/therapeutic materials
Images of these can be scanned onto the EPR with patient consent or keep partially completed
items in the red file. Upon the patient’s discharge, give the document back to the patient unless
they request it is destroyed. Enter an entry onto the EPR detailing patient decision to take back or
rationale to destroy the item.
15.0 Copyright materials
Where copyright explicitly prevents the storage of completed material / documentation, alternate
storage arrangements must be sought from the Head of Data Privacy or Data Privacy Manager.
16.0 Training Needs
All staff required to scan clinical documentation onto clinical records are required to undertake
Clinical Document Scanning Training via the Trusts e-learning platform. This session ensures
that staff are fully aware of the principles of this Policy and the processes to be adhered to when
undertaking the task of scanning onto clinical records. This training is a one-off session, to be
repeated where there are performance issues, a change in post or following return to work after
long term absence, as required by management. Records of attendance at training sessions and
assessment outcomes will be requested from the workforce team by the team manager. Local
managers must ensure that staff members are competent by completing the SOP competency
framework and ensuring that local internal quality assurance checks are undertaken.
Training in EPR functionality will be provided by the Leicestershire Health Informatics Service
(LHIS) to ensure that staff required to scan onto the EPR as part of their role are fully competent
in the use of the functionality. Quick Reference Guides are available as aide-memoirs for the
technical aspects of the EPR.
17.0 Communication
Regular communications will be distributed by the Clinical Document Scanning Team via the
intranet, newsletters, meetings with services/teams, error correction figures are submitted to
teams / team managers. There is representation by the Team at forums such as the Data
Privacy Committee (who the team report into) and IM&TDG in addition to the distribution of
incident data and recording of any risks on applicable systems.
Page 21 of 29
18.0 Monitoring Compliance and Effectiveness
Ref
Minimum
Requirements
Evidence for
Self-
assessment
Process for
Monitoring
Responsible
Individual /
Group
Frequency
of
monitoring
P11
Weekly batches of
scanned
documentation
Section 7
Audit
LPT Scanning
Team
Monthly
P11
Minimum check of
20% following
reduction from
100% & 50%
second level check
Section 7
Audit
LPT Scanning
Team
Monthly
P14
Policy understood,
SOP & competency
locally completed for
each staff member
Section 7.1
SOP &
Competency
sign off
Line Managers
As required
P14
Audit
Section 8
Audit
LPT Scanning
Team / Line
Managers
3 monthly
P15
Staff checking paper
documentation
against the scanned
copy
Section 7
Quality
assurance
LPT Scanning
Team
Monthly
P15
Testing of
equipment
Section 7
Testing
Staff member
6 monthly
P15
Maintenance of
equipment
Section 7.1
Cleaning &
testing
Staff member
Monthly
P15
100% internal check
for submitting
batches over 2
weeks late
Section 7.2
Staff member
Line manager
Weekly
P16
Non Conformity Log
Section 7.2
Reporting of
process
interruptions
Staff member
As required
P16
Internal QA
checking
Section 7.4
Monitor
errors locally
Line Managers
Weekly
P17
Ceasing external
QA checks where
errors creep up to
≥10%
7.5
Clinical
Document
Scanning
Team
Clinical
Document
Scanning Team
Monthly
P17
Services to achieve
10% or less error
correction rate
Section 7.9
Self audit,
receipt of
Error
Correction
Figures
Line Managers
Monthly
P18
Audit
Section 7
Audit
LPT Scanning
Team
Monthly
Page 22 of 29
Ref
Minimum
Requirements
Evidence for
Self-
assessment
Process for
Monitoring
Responsible
Individual /
Group
Frequency
of
monitoring
P18
Reportable incident
where documents
are missing,
uploaded to the
incorrect record or
error documents are
not returned within 4
weeks
Section 7.5
Clinical
Document
Scanning
Team
Clinical
Document
Scanning Team
As required
19.0 Standards/Performance Indicators
TARGET/STANDARDS
KEY PERFORMANCE INDICATOR
All Trust staff should be aware that the
organisation performs comprehensive
System access audit trails on a regular basis.
100% of system access audits provide
evidence of legitimate and authorised
access only.
Adherence and retention of accreditation to British
Standard 10008:2014-1 Legal Admissibility and
Weight of Evidence of Information Stored
Electronically
Internal audit
Local error correction figures
External audit by British Standards
Institute
All staff undertaking Clinical Document Scanning to
be trained in both system & 10008 processes
100% of staff to be trained
20.0 References and Bibliography
This policy was drafted with reference to the following:
Code of Practice for Legal Admissibility and Evidential Weight of Information Stored
Electronically (BSI 2014)
IGA Records Management Code of Practice for Health and Social Care 2016
The Civil Evidence Act 1995
Confidentiality: NHS Code of Practice
The General Data Protection Regulation and Data Protection Act 2018
The Electronic Communications Act 2000
The Computer Misuse Act 1990
Page 23 of 29
Staff member trained in all required
areas, completed competency
framework*
Scan and process within EPR*
Perform check of own work referring to
training, policies & processes
Internal QA check (NOT
performed by the scanner
operative)*
Submit for external QA check within a
week of scanned (submitted later than
2 weeks requires 100% local check)*
Clinical Document
Scanning QA team
receive*
Clinical Document Scanning
QA team perform QA
check*
No errors found *
Archived by Clinical Document
Scanning QA team for secure
destruction *
Returned for corrective action*
Correct errors(if the error
documents are not resubmitted
by 30 days –an eIRF is opened)*
Clinical Document Scanning Quality
Assurance Team responsibility
Service / Team responsibility
Errors found *
Escalate to local line manager if
errors are not resolved after 2
returns –local management action
required
Implement document
scanning
Clinical Document Scanning
High Level Process
CDS_High Level Process_v1_20200827
Errors
found
No errors
found
Colour Key
*Refer to specific process for services/team
*Refer to specific process for Clinical Document Scanning Team
Correct
errors
If scanning a
Document does not
produce a good scan
after 3 attempts –
raise as an
exception
If there is an
Interruption to the
scanning process or
a paper document is
removed post
scanning – log this
as a non conformity
Appendix 1
Page 24 of 29
Clinical Document Scanning Team QUALITY ASSURANCE Check Log
Service:
Batch date
from:
Batch date
to:
Date
Received:
Batch number:
Recheck?
If Yes -
amount for
recheck:
Total number
of scans in
batch:
Is a
Management
check
enclosed?
If yes -
management
check
amount:
Management
check %
remainder in
batch:
Amount
checked:
Check %
For completion by QUALITY ASSURANCE Team
FOR COMPLETION BY SERVICE
Document
date
yyyymmdd
Document
received
date /
date on
EPR (if
applicable)
yyyymmdd
NHS
Number
xxx xxx
xxxx
Correctly
named file
on
Electronic
Patient
Record
Y/N
Document
Type
(description
of
document)
Uploaded
to correct
patient
Y / N
Original
document
or Copy
Original /
Copy
Issues
Y / N
Issue
Details
(allows
multiple)
Comment
Document
removed
from
batch?
Y/ N
(service to
complete)
Reason
for
removal
from
batch
Date Corrected
yyyymmdd
Total Number of errors:
Error Percentage %
Checked by (Sign name):
on behalf of Scanning Quality Assurance Team
Checked by (print name):
Date:
ACTIONS COMPLETED (to be completed by Service):
Print & Sign Name
Designation:
Date:
Appendix 2
Sample Quality Assurance log sheet
Page 25 of 29
Training Requirements
Training Needs Analysis
Training topic:
Clinical Document Scanning
Type of training:
(see study leave policy)
☐ Mandatory (must be on mandatory training register)
Role specific
☐ Personal development
Directorate (s) to which the
training is applicable:
Adult Mental Health & Learning Disability Services
Community Health Services
☐ Enabling Services
Families Young People Children
☐ Hosted Services
Staff groups who require
the training:
Any staff required to scan clinical documentation onto the
EPR (Electronic Patient Record)
Regularity of Update
requirement:
As determined by line manager
Who is responsible for
delivery of this training?
Self – training available via ULearn platform
Have resources been
identified?
Yes
Has a training plan been
agreed?
Yes
Where will completion of
this training be recorded?
ULearn
☐ Other (please specify)
How is this training going to
be monitored?
Via line managers, quarterly reports provided from the
Clinical Document Scanning Team to the services from
Workforce of staff completion
Appendix 3
Page 26 of 29
Appendix 4
The NHS Constitution
The NHS will provide a universal service for all based on clinical need, not ability to
pay. The NHS will provide a comprehensive range of services
Shape its services around the needs and preferences of individual
patients, their families and their carers
Respond to different needs of different sectors of the population
Work continuously to improve quality services and to minimise
errors
Support and value its staff
Work together with others to ensure a seamless service for patients
Help keep people healthy and work to reduce health inequalities
Respect the confidentiality of individual patients and provide open
access to information about services, treatment and performance
Page 27 of 29
Stakeholders and Consultation
Key individuals involved in developing the document
Name
Designation
Sam Kirkland
Head of Data Privacy / Data Protection Officer
Mary Stait
Data Privacy Manager
Claire Mott
Clinical Systems Change Lead – Clinical Document Scanning
Rachel Lowe
Information Request Officer - Clinical Document Scanning
Circulated to the following individuals for comment
Name
Members of Data Privacy Committee
Appendix 5
Page 28 of 29
Due Regard Screening Template
Section 1
Name of activity/proposal
Clinical Document Scanning Policy
Date Screening commenced
22/02/2021
Directorate / Service carrying out the
assessment
Finance and Performance
Name and role of person undertaking
this Due Regard (Equality Analysis)
Claire Mott, Clinical System Change Manager
Give an overview of the aims, objectives and purpose of the proposal:
AIMS:
The aim of this policy is to set out how the scanning of clinical documentation will be undertaken
within the organisation (Leicestershire Partnership NHS Trust).
OBJECTIVES:
The purpose of this policy is to ensure that standards as defined in BIP 0008 British Standard
10008:2014 are adhered to when scanning clinical documentation for the purpose of destroying
the original copy.
Section 2
Protected Characteristic
If the proposal/s have a positive or negative impact
please give brief details
Age
Positive
Disability
Positive
Gender reassignment
Positive
Marriage & Civil Partnership
Positive
Pregnancy & Maternity
Positive
Race
Positive
Religion and Belief
Positive
Sex
Positive
Sexual Orientation
Positive
Other equality groups?
Positive
Section 3
Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a
clear indication that, although the proposal is minor it is likely to have a major affect for people from an
equality group/s? Please tick appropriate box below.
Yes
No
High risk: Complete a full EIA starting click here
to proceed to Part B
Low risk: Go to Section 4.
Section 4
If this proposal is low risk please give evidence or justification for how you reached this decision:
This policy defines the processes requiring adherence for the processing of patient clinical
documentation and the conversion into scanned images that are legally admissible.
Signed by reviewer/assessor
Date
25/02/2021
Sign off that this proposal is low risk and does not require a full Equality Analysis
Head of Service Signed
Date
25/02/2021
Appendix 6
Page 29 of 29
Appendix 7
DATA PRIVACY IMPACT ASSESSMENT SCREENING
Data Privacy impact assessment (DPIAs) are a tool which can help organisations identify the
most effective way to comply with their data protection obligations and meet Individual’s
expectations of privacy.
The following screening questions will help the Trust determine if there are any privacy issues
associated with the implementation of the Policy. Answering ‘yes’ to any of these questions is
an indication that a DPIA may be a useful exercise. An explanation for the answers will assist
with the determination as to whether a full DPIA is required which will require senior
management support, at this stage the Head of Data Privacy must be involved.
Name of Document:
Clinical Document Scanning Policy
Completed by:
Claire Mott
Job title
Change Lead
Date 22/02/2021
Screening Questions
Yes /
No
Explanatory Note
1. Will the process described in the document involve
the collection of new information about individuals?
This is information in excess of what is required to
carry out the process described within the document.
No
2. Will the process described in the document compel
individuals to provide information about them? This is
information in excess of what is required to carry out
the process described within the document.
No
3. Will information about individuals be disclosed to
organisations or people who have not previously had
routine access to the information as part of the
process described in this document?
No
4. Are you using information about individuals for a
purpose it is not currently used for, or in a way it is
not currently used?
No
5. Does the process outlined in this document involve
the use of new technology which might be perceived
as being privacy intrusive? For example, the use of
biometrics.
No
6. Will the process outlined in this document result in
decisions being made or action taken against
individuals in ways which can have a significant
impact on them?
No
7. As part of the process outlined in this document, is
the information about individuals of a kind particularly
likely to raise privacy concerns or expectations? For
examples, health records, criminal records or other
information that people would consider to be
particularly private.
No
8. Will the process require you to contact individuals
in ways which they may find intrusive?
No
If the answer to any of these questions is ‘Yes’ please contact the Data Privacy Team via
Lpt-dataprivac[email protected]
In this case, ratification of a procedural document will not take place until review by the Head of
Data Privacy.
Data Privacy approval name:
Sam Kirkland -
Date of approval
25/02/2021
Acknowledgement: This is based on the work of Princess Alexandra Hospital NHS Trust