Health Records ManagementPractitioner

Information Governance Policy TeamNHS Connecting for Health

Key Learning Points

1. Responsibilities for health records2. Record Lifecycle Management3. Auditing current health records practices & procedures4. Undertaking an records inventory survey of existing

health records systems5. Drafting/maintaining the organisation’s health records

management policy6. Drafting/maintaining the organisation’s health records

management strategy & associated action plan7. Raising awareness of the importance of health records

management throughout your organisation

Responsibilities for Records

‘All individuals who work for an NHS organisation are responsible for any records which they create or use in the performance of their duties….. any record that an individual creates is a public record.’

Records Management: NHS Code of Practice

There are therefore INDIVIDUAL, STATUTORY & MANAGERIAL responsibilities for all NHS records, including health records

Record Lifecycle Management

Create Use Retention DisposalAppraisal

Clo

se R

eco

rd

Be aware ControlMonitor

Information RequestsInformation Requests

NHS records may be subject to NHS records may be subject to information requestsinformation requests

Health Records Policies & Procedures

Procedure Policy and Procedure manual

Key management toolBasis for specific training

Auditing Health Records Policies & Procedures – The Audit Cycle

The audit cycle

Undertaking a Records Inventory Survey

Guidance has been produced to help those organisations that have not yet started to establish a records inventory or are still in the in the early stages of completing one

The guidance & a records inventory survey form are available in the records management roadmap www.connectingforhealth.nhs.uk/infogov/records and they are summarised in the following slides.

Practical Steps

A health records inventory is one component of the complete records inventory

It can be completed in 3 steps

Insert 3 step diagram

 Step 3

8 Databases storing research information, etc

Health Records

 

7 Electronic records replicating PAS e.g. waiting and clinic lists

 6 Standalone clinical systems

  Step 2

5 Clinical systems (PAS fed)

 4 Patient Administration Systems

(PAS)

Step 1

3 Scanned, microfilm records

2 Admission, day, ward books, diaries, index cards

1 Paper health records

Distributing & Completing the inventory

Distributing & Completing the Inventory Forms

Aggregating the Inventory Form

Benefits of a Health Records Inventory#1

Improves compliance with: Records Management: NHS Code of Practice IG Toolkit requirements NHS Litigation Authority’s risk management

standards Standards for Better Health Professional standards

Benefits of a Health Records Inventory#2

Informs the Board’s Assurance Framework Identifies managers and ‘owners’ Identifies sharing arrangements Identifies the format in which records are

stored Allows mapping to retention schedules Ensures appropriate training Identifies storage conditions Identifies security arrangements

Keeping the Inventory Up to Date

The inventory needs to be accurate & kept up to date

Health records manager must keep the health records inventory up to date

Records management lead has responsibility for keeping the corporate inventory up to date

Health Records Management Policy

A health records management policy applies to all types of health record regardless of the media on which they are held

Its sets out a framework within which to develop specific policies and practices to ensure that health records are managed and controlled

Model documentation is available in the records management roadmap

Aims of a Health Record Management Policy

are available when needed can be accessed can be interpreted can be trusted can be maintained through time are secure are retained and disposed of appropriately staff are appropriately trained

To ensure that health records:

Drafting and maintaining a Health Records Management Strategy

The health records management strategy applies to all health records of all types regardless of the media on which they are held;

It should be an integral part of the organisation’s wider records management strategy and be compliant with the organisation’s records management policy. If the strategy and policy have not yet been written, model documentation is available in the records management roadmap

Aims of the Records Management Strategy

Responsibility and accountability Record quality Management Security Access Audit Training

Why do we need a Health Records Management Strategy? To provide a robust baseline from which to move forward; To identify how the management of health records is currently

structured; To identify what health records the organisation generates and

how they are archived and stored; To enable the organisation to meet existing and future demands

for health records management; To ensure that the organisation meets it’s legal and statutory

obligations in respect of health records; To help NHS organisations to improve the standard of health

records management and to raise the profile of the service within the organisation.

Tools to inform the strategy Records inventory survey Audit of HRM policies & procedures Assessment of environmental conditions Access controls for storage areas Assessment of tracing/tracking systems Mapping of records to retention schedule Review retention & destruction procedures Training provision

The Planning Cycle

1. Where are we now?(Position Statement)

2. Where do we want to be?(Goals & Objectives)

3. How are we going to get there

& how will we know what progress

We are making?(Action Points

& Monitoring Criteria)

Where are we now?#1 (Position Statement)

Results of baseline audit - list the types and numbers of records and locations where they are stored and who is responsible for managing them;

Describe environmental conditions; Document security & access arrangements to

storage areas;

Where are we now?#2 (Position Statement)

Document retention periods for all types of records in line with the current retention schedule and indicate the organisation’s compliance status;

List existing policies & procedures including retention, weeding, archiving & destruction.

Developing the Action Plan(Identifying Goals & Objectives)

Is there a designated manager responsible for each collection of records?

Are you storing more records than necessary? Is there sufficient storage space for them? Are environmental conditions appropriate & safe? Do you need additional storage? Do you need to look at archiving solutions? Are disposal & destruction arrangements appropriate?

Where do we want to be? (Goals & Objectives)

Goals & objectives should be SMART SpecificMeasurableAchievableRealisticTime-bound

Developing the Action Plan#1 (How Are We Going To Get There?)

Action Points • Identify tasks related to each of the goals and

objectives:-• Specify timescales• Specify resources required• Specify responsibility for action(s)

• Quantify resources required & produce a business case to secure additional resources if necessary

Developing the Action Plan (How Will We Know What Progress We Are Making?) Monitoring Criteria

Determine monitoring criteria & timescales:- Specify how progress will be monitored

and when Specify how progress will be reported

Schedule monitoring meetings aligned with the timescales & milestones in the strategic plan

The Health Records Management Strategy – Making it Happen

The strategy should:- Contain a realistic action plan with achievable

milestones and timescales for implementation; Identify resources required to achieve the

plan; Identify possible risks, which may jeopardise

the plan; Have regular reviews of progress built in to it.

Keeping The Strategy Under Review

Review the strategy annually Maintain close links with the IM&T & corporate

records management strategies Maintain close links with the IGT assessment

process

Raising awareness of Health Records Management – Why?

To ensure that everyone knows who has the lead role for records management in the organisation

To ensure that all members of staff understand their personal responsibilities in respect of health records management

To ensure that issues and progress on health records management are routinely fed back to the Board

Further Guidance and useful links

Records Management NHS Code of Practice

DH: Records Management NHS Code of Practice

Information Governance Toolkit

www.igt.connectingforhealth.nhs.uk/ Records Management

Roadmapwww.connectingforhealth.nhs.uk/infogov/records NHS IG Policy Team website

(Find out more about IG)www.connectingforhealth.nhs.uk/infogov

Department of Health website www.dh.gov.uk/en/Home