Patient Medical Record Scanning Log Form
Log each patient record scanning activity. This form is for operational tracking only—do not enter sensitive information.
Staff Name
*
First Name
Last Name
Date and Time of Scan
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Record Reference Number
*
Type of Document Scanned
*
Please Select
Admission Form
Discharge Summary
Lab Report
Imaging Report
Consultation Note
Other
Department or Location
*
Please Select
Admissions
Radiology
Laboratory
Medical Records
Other
Scan Status
*
Completed
Pending
Error/Rescan Needed
Attach Scanned File (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Notes
Log Scan
Should be Empty: