EHR? The Paperwork You Must Maintain

What should be done with the hard copy of the intake paperwork when transitioning to an EHR?

Risk Management

EHR? The Paperwork You Must Maintain

Many doctors question what paperwork must be maintained as they transition to EHRs.

For example, if a new patient fills out the patient intake form (paper form) and the doctor or a staff member transfers the information into the EHR notes what should be done with the hard copy of that intake paperwork? Should it be saved or shredded?

The NCMIC Claims Department representatives—the people who work directly with doctors in the defense of malpractice claims—advise doctors to scan and/or make part of the permanent record any written documents. At a minimum,they suggest preserving anything that includes the patient’s writing and/or signature.

For example, if a patient fills out a form, such as a patient history form, preserving a record of the document in the patient’s handwriting is important. It can be very helpful to a doctor’s defense in the event of a malpractice or board allegation.

If the EHR system has a scanning feature, the system will attach the scanned documents to the patient’s record. This is ideal because everything will be in one place. If the EHR system does not provide for document scanning, maintain the paper documents separately. Then, implement a process to produce the entire document, including the hard copies, if they are needed later.

This process may seem cumbersome and unnecessary at first glance.However, the process a doctor has in place is often invaluable. It can make the difference between a positive or negative outcome in a lawsuit or board action.

The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.