CAP Transfusion Medicine Checklist question CAP TRM.32350 states:  Records QC  "A process in place to verify that copies of records are complete, legible, and contain the original content.  Note:  This item applies to both electronic and paper records.  Laboratories converting data onto another medium for storage and retention must have a process in place to verify the accuracy, legibility, and completeness of the records before original documents are discarded.  This checklist item would apply to any situation in which the lab makes a copy of an original."

 

I have spoken with CAP about this item and am still a bit confused as to what they want.  We have used SoftBank since 2008.  Prior to 2008, we used a manual paper system so we have not converted patient data from one computer system to another.  CAP said this does not apply when you print a report from a computer, but applies anytime you make a Xerox copy.  I would appreciate any input on how other labs are meeting this requirement.  Thank you!

It is not very often that I make a copy of a record.   What are you copying?   I would think this may apply to scanning records too.  Sorry, I am no help.

I am scanning old paper records into a data base as pdf. files so that I can shred them before we drown in paper.

 

My process is a spread sheet on which I identify: the document type, the header into which the record is scanned in the database, how many pages were scanned in, by whom and the date. Then we verify that the documents were properly scanned in using the same spread sheet: how many pages appear in the scanned file (should match what we scanned), the documents appear under the correct header in the database and that the pages are all legibile/complete. Someone actually flips through the pages to make sure that every page was scanned and is legible. The number of pages you should actually look at depends on the size of the file.

 

CAP gave me some definite guidelines about that - if the file is below a certain size (sorry, I don't remember how many pages that is) you need to make sure that every page is present. If the file is above a certain size you need to review a percentage of the total number of pages. Our scanning system only does about 50 pages at a time, so we have to look at every page. Fortunately I have an eager beaver on the evening shift who hates to sit with nothing to do and actually enjoys doing tedious things and she will be flipping through pages for me. Slowly, slowly we will get piles of paper scanned. I believe that this system will satisfy CAP requirements based on my conversation with them.

 

If we photocopy a record, for whatever reason, policy states that you write 'Copy' on the bottom of the document, along with your initials and the date. By doing so you have verified that the copy is complete and legible. I've gone through several inspections with this policy and there haven't been any comments or questions.

Edited February 5, 201411 yr by AMcCord