Journal of Modern Medical

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rezayi S, saeedi S. Guidelines and standards for archiving and managing clinical documents and images: A narrative review. JMIS 2020; 6 (4) :60-72
URL: http://jmis.hums.ac.ir/article-1-262-en.html

Aim: Most clinical care providers such as hospitals need to scan patients' records and save them electronically. The purpose of this review study is to determine the principles and steps related to scanning medical records in Iran.
Information sources or data: In this study, reputable databases such as SID, Scopus, Web of Science, PubMed, and Google Scholar were searched.
Selection methods for study: The keywords "scan" and "medical record" were searched in reputable databases. The articles' date was limited between 2010-2020 in English databases and between 2005-2020 in Persian databases. A total of 150 articles were retrieved, and after applying the inclusion and exclusion criteria (year of authorship, relevance, access to article texts, and non-duplication), we reached 15 studies, which were thoroughly reviewed. Finally, a conceptual model was drawn for the extracted framework.
Combine content and results: After reviewing the relevant texts, the process of scanning medical records in eight stages of document preparation, document scanning, quality assurance (prevention of defects), storage, post-scanning processes, retention and destruction, quality control (identification of defects), tracking and auditing of medical records were examined. The standards required for electronic archiving of medical records are based on case studies including BS10008, DICOM, LOINC, CEN 13606, and HL7.
 
Conclusion: Scanning medical records and managing them electronically helps reduce common errors in older archiving methods to zero.