What to do with paper chart

Legality of paper

Much of the requirements of electronic documents transfer directly from the legal realm of the paper chart.  As this may vary from time to time and from one jurisdiction to another the following can only be construed as a potential approach based on the following tenets.

1. You are required to keep medical records that you generate for a specific length of time.
2. There is no obligation to keep copies of medical records generated by outside agencies (consultants, hospitals...) who keep the original. (although it is good record keeping to do so)
   

Thus according to the CMPA that, in Canada, the output of paper-scanning *must* include the retention of a legible representation of the *image* if the paper original would be destroyed. This means that what is retained digitally cannot be *only* "interpreted text" (i.e. not "just" OCR), if people had even taken the trouble to do this conversion. Also inadequate would be to get your secretary to (for example) transcribe only a report "impression" into an EMR, and to then discard an original paper report.

If the paper is to be discarded, then a legible representative likeness of what is supposed to have been a legible original (see footnote) *must* have been generated, and *must* be able to be later reproduced if requested by the court. Traditionally photocopies or microfiche have been acceptable.  Whether as a computer PDF file "layer", or as a standalone PDF consisting of the image, or whether as any other legible *image* representation (JPEG, TIFF), is apparently – at least in Canada – nowhere specified. Apparently, the relevant Canadian statutes are defined in provincial commercial law in which PDF was either contended, or was at least by implication, acceptable subject to the image retention stipulation.

Provided the aforementioned conditions were met, a PDF *would* be acceptable as a substitute for your original medical chart.  There is more leeway for documents in the chart of external origin.

Footnote: There is a risk in scanning a paper original of borderline to poor legibility, and then discarding the original, since the scanned version would also be illegible and with the original discarded no way to refute that the original had been improperly handled. This was the warrant in a legal case (I think American) where an error had been made in the interpretation of a numeric result. When it did prove possible to retrieve the paper original, it turned out that the scanned version was not appreciably different than (i.e. it had faithfully reproduced) illegibility in the original. The defendant were lucky, for s/he nowhere on record was their scanning "protocol", for example what resolution or software they had used and constituting "metadata" not always stored in a PDF. So… caveat emptor on the merits of maintaining an office manual in which office procedures get documented for the record.