record management
DESCRIPTION
TRANSCRIPT
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Records Management and the NHS Code of Practice (Foundation)
Information Governance Policy TeamNHS Connecting for Health
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Key Learning Points
What is Records Management? What is a record? Who is responsible for records? The Records Management: NHS Code of
Practice Benefits of records and records management The Records Lifecycle
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What is Records Management?
• Systematic management of all records
• Paper and electronic records
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What is a record?
Records document each and every activity
They are the organisation’s memory
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Types of Records
Health records
X-rays
Administrative records
Photographs, slides, and other images
Microfilm
Audio and video tapes, cassettes, CD-ROM
Diaries
E-mails, text messages
Etc, etc, etc
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Who is responsible 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
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The Records Management: NHS Code of Practice
A guide to:
• Standards of best practice
• Legal requirements
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What does the Code of Practice replace? HSC 1999/053 – For the Record
HSC 1998/217 – Preservation, Retention and Destruction of GP General Medical Services Records Relating to Patients
HSC 1998/153 – Using Electronic Patient Records in Hospitals: Legal Requirements and Good Practice.
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Guidance aims
Establish a Records Management framework Clarify legal obligations Detail required actions Explain the requirement for permanent
preservation Set out recommended minimum retention
periods Where to find further information
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Records are a valuable resource!
They support:
Patient care
Administrative decision making
Legal requirements
Clinical audits
Patient choice
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Benefits of Records Management
Better use of space
Better use of time
Improved control of resources
Compliance with legislation
Reduce costs
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Record Lifecycle
Any record created by an individual, up to its disposal, is a public record and subject to Information Requests
Create Use Retention DisposalAppraisal
Clo
se R
eco
rd
Be aware ControlMonitor
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Record Creation
Each function must document all activities and ensure records are:
AccurateCompleteEasy to find and retrieve
Credible and Authoritative
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Information Quality Assurance
Managers must ensure that staff are trained
What?How?Why?
What to recordHow to recordWhy to record
How to validate
& update records
AND
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Record Keeping
What records are held, where and who manages them?
ing
Records Inventory Survey
MANUAL RECORDS INVENTORY FORM (EG PAPER, X-RAY, MICROFORM ETC)
1 Yes
No
2 Name of the record
3
4 Yes If 'Yes', where?
No
5 Name
Job Title
Tel No.6
Other Specify
Microform
Who is responsible for managing the record?
Format of the recordPaper Film/X-ray
Do you store records in the dept?
Alternative name of the record (where appropriate)
Are duplicates of the record held?
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Records Inventory Survey
A stepped approach is recommended
Non-HealthRecords
Step 4 Estates, IM&T, Other
Step 3 Administrative records, Purchasing & supplies
Step 2 Human Resources, Finance
Health Records
Step 1 PAS or PAS- fed Clinical Systems
Paper based, scanned, microform records etc.
Standalone clinical systemsDatabases e.g. research
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Record Maintenance
Control record movement and location
Storage areas should be clean and tidy
Stores should be secure
Secondary storage for non-current records
Contingency/Business Continuity Plans
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Scanning
Scanning paper records can reduce storage requirements
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Scanning
However:
• Costs of initial conversion
• Consult with The National Archives
• Protect the evidential value
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Disclosure and Transfer of Records
Statutory provisions limit the disclosure of records
• Freedom of Information Act 2000
• Data Protection Act 1998
• The Abortion Regulations 1991
• Crime and Disorder Act 1998
• Public Records Act 1958
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Disclosure and Transfer of Records
If you have any concerns, contact, as appropriate, your organisation’s:
• Caldicott Guardian;
• Information Security Officer;
• Data Protection Officer;
• Health Records Manager; or
• Records Manager.
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Retention and Disposal Arrangements All organisations should have Record Retention and Disposal policies to ensure records are annually selected for:
• Secondary storage (eg off-site or scanned etc)
• Permanent archival preservation
• Destruction
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Record Destruction
• Records must be destroyed in a secure environment
• Contractors must abide by Confidentiality Agreements
• Maintain a register of the destruction of records
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Further Guidance and useful links
DH: Confidentiality NHS Code of Practice
DH: Records Management NHS Code of Practice
The Data Protection Act 1998
The Freedom of Information Act 2000
The IG Policy Team Website Records Management Roadmap
The Department of Health website
Information Commissioners Office website (more information and guidance on FOI and DPA)