{"id":2156,"date":"2019-10-10T12:18:00","date_gmt":"2019-10-10T16:18:00","guid":{"rendered":"https:\/\/live-coto.pantheonsite.io\/?post_type=resource&#038;p=2156"},"modified":"2025-01-21T14:57:21","modified_gmt":"2025-01-21T19:57:21","slug":"electronically-scanning-client-information","status":"publish","type":"resource","link":"https:\/\/www.coto.org\/resources\/electronically-scanning-client-information\/","title":{"rendered":"Electronically Scanning Client Information"},"content":{"rendered":"\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-background\">\n    <div class=\"section-header \">\n        <h2>Background<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p>Jason is an occupational therapist practicing psychotherapy in a mental health facility. As part of each new session Jason uses standardized paper and pencil screening assessments. Jason often use worksheets as part of the clinical intervention with his clients. Up until now Jason has been summarizing these clinical assessments and interventions in the clinical notes and he securely maintains the original paper copy. The organization has implemented a new electronic medical record system.<\/p>\n\n\n\n<p>Jason wonders if he scans his paper assessments, is it also necessary to retain the original paper copy or can it be destroyed?<\/p>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-considerations\">\n    <div class=\"section-header \">\n        <h2>Considerations<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<ul class=\"wp-block-list\">\n<li>Jason considers the purpose of record keeping. He understands that a client record is a medical legal document and a source of evidence and accountability. He is aware that the primary purpose is to officially record events, decisions, interventions, and clinical plans. The College\u2019s\u00a0<a href=\"https:\/\/www.coto.org\/resources\/standard-for-record-keeping-2023\/\" data-type=\"resource\" data-id=\"1310\">Standards for Record Keeping<\/a>\u00a0is a resource and outlines the minimum expectations for all occupational therapists.<\/li>\n\n\n\n<li>Jason considers if there is a need to retain the original clinical data and wonders whether in the absence of this original data would his documentation stand sufficiently alone.&nbsp; To gain additional information he goes to the College website, and under Standards &amp; Resources he reviews the Standard for Record Keeping.<\/li>\n\n\n\n<li>Jason questions whether his organization has any requirements that the original data be maintained.<\/li>\n<\/ul>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-outcome\">\n    <div class=\"section-header \">\n        <h2>Outcome<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<ul class=\"wp-block-list\">\n<li>Jason considers the content of the paper and pencil assessment forms and determined that the existence of the original data may add credibility and supports his recommendation.&nbsp;&nbsp;<\/li>\n\n\n\n<li>Jason reviews Indicator 3.8 of the Standards for Record Keeping regarding the inclusion of electronic clinical data. In the Standard it states that \u201cconverting data to an electronic format, for retention purposes, is appropriate as long as the integrity of the data is upheld.\u201d If transferring the data would alter its integrity then it would be better to retain the hard copy, with a notation in the electronic health record, indicating its existence and where it can be found.&nbsp;<\/li>\n\n\n\n<li>Jason decides to scan the assessment data and selected worksheets and save it in the client\u2019s electronic clinical record. He uses his clinical judgement to determine what data are best summarized in written format and what clinical data are best represented by an image. He acknowledges that in circumstances where the quality or completeness of the data is not optimal then he will note where the original data is kept for reference.<\/li>\n<\/ul>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-discussion\">\n    <div class=\"section-header \">\n        <h2>Discussion<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p>The College expects that occupational therapists use their clinical judgement and rationale when determining if clinical data is appropriate to scan into a client\u2019s electronic clinical record. Health Information Custodians (HIC) do not need to keep multiple copies of the exact same personal health information. If the integrity of the data is kept intact during its transition to the electronic format, it is reasonable to assume that a scanned version of the personal health information is essentially the same thing as the paper copy.<\/p>\n\n\n\n<p>Organizations will often have policies and procedures that occupational therapists are also expected to adhere to when including electronic data into the clinical record. If an occupational therapists determines that the data does not need to be kept the destruction of personal health information should be completed in in a secure manner as outlined in the Standards for Record Keeping \u2013 Standard 7 &#8211; Retention and Destruction and organizational policies.<\/p>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-references\">\n    <div class=\"section-header \">\n        <h2>References<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p><a href=\"https:\/\/www.coto.org\/resources\/standard-for-record-keeping-2023\/\" data-type=\"resource\" data-id=\"1310\">Standards for Record Keeping<\/a><\/p>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n\n<div class=\"content-section-block has-fade-in-up  align wp-block-acf-content-section\" id=\"section-contact\">\n    <div class=\"section-header \">\n        <h2>Contact<\/h2>\n            <\/div>\n\n    <div class=\"content-section\" aria-hidden=\"false\">\n        <div class=\"acf-innerblocks-container\">\n\n<p>If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570\/416.214.1177&#215;240 or&nbsp;<a href=\"mailto:practice@coto.org\">practice@coto.org<\/a>.<\/p>\n\n\n\n<p>Want more case studies?\u00a0<a href=\"http:\/\/bit.ly\/COTOsignup\" target=\"_blank\" rel=\"noreferrer noopener\">Sign up<\/a>\u00a0to stay up to date and receive the latest cases when they\u2019re released.\u00a0\u00a0<\/p>\n\n<\/div>\n    <\/div>\n<\/div>\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"template":"","meta":{"_acf_changed":false,"advanced_seo_description":"Read our case study about electronically scanning client information as an occupational therapist.","jetpack_seo_html_title":"Electronically Scanning Client Information","jetpack_seo_noindex":false,"footnotes":""},"resource-audience":[17],"resource-topic":[33],"resource-type":[6],"class_list":["post-2156","resource","type-resource","status-publish","hentry","resource-audience-registrants","resource-topic-record-keeping","resource-type-case-studies"],"acf":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource\/2156","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource"}],"about":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/types\/resource"}],"author":[{"embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/users\/1"}],"version-history":[{"count":4,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource\/2156\/revisions"}],"predecessor-version":[{"id":4762,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource\/2156\/revisions\/4762"}],"wp:attachment":[{"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/media?parent=2156"}],"wp:term":[{"taxonomy":"resource-audience","embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource-audience?post=2156"},{"taxonomy":"resource-topic","embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource-topic?post=2156"},{"taxonomy":"resource-type","embeddable":true,"href":"https:\/\/www.coto.org\/wp-json\/wp\/v2\/resource-type?post=2156"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}