Records Management and the NHS Code of Practice (Foundation)

Information Governance Policy TeamNHS Connecting for Health

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

What is Records Management?

• Systematic management of all records

• Paper and electronic records

What is a record?

Records document each and every activity

They are the organisation’s memory

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

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

The Records Management: NHS Code of Practice

A guide to:

• Standards of best practice

• Legal requirements

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.

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

Records are a valuable resource!

They support:

Patient care

Administrative decision making

Legal requirements

Clinical audits

Patient choice

Benefits of Records Management

Better use of space

Better use of time

Improved control of resources

Compliance with legislation

Reduce costs

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

Record Creation

Each function must document all activities and ensure records are:

AccurateCompleteEasy to find and retrieve

Credible and Authoritative

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

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?

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

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

Scanning

Scanning paper records can reduce storage requirements

Scanning

However:

• Costs of initial conversion

• Consult with The National Archives

• Protect the evidential value

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

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.

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

Record Destruction

• Records must be destroyed in a secure environment

• Contractors must abide by Confidentiality Agreements

• Maintain a register of the destruction of records

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)