€¦ · web view · 2018-03-29policy number . v1. october 2015. page 38 of 141. v1. v1. october...

Version 1.2.1 May 2016 of 141

Policy Number LCH-Corp19

This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.Part A – Information about this DocumentPolicy Name Records Manual PolicyPolicy Type Board Approved (Trust-wide) ☐ Trust-wide ☐ Divisional / Team / Locality ☐

Action No Change ☐ Minor

Change ☐ MajorChange ☐ New

Policy ☒ No LongerNeeded ☐

Approval

As Mersey Care’s Executive Director / Lead for this document, I confirm that this document:a) complies with the latest statutory / regulatory requirements,b) complies with the latest national guidance,c) has been updated to reflect the requirements of clinicians and officers, andd) has been updated to reflect any local contractual requirements

Signature: Date:Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document New terminology when reading this Document

Part C – Additional Information Added (to be used with ‘Major Changes’ only)Section /

Paragraph NoOutline of the information that has been added to this document – especially where it may

change what staff need to do

Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)Accountable Director

Recommending Committee

Approving Committee


Next Review Date

LCH Policy Alignment Process – Form 1

SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESSAll Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of

abuse, or by professional judgement made as a result of information gathered about the child / adult;

knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they

have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your

role); ensuring contemporaneous records are kept at all times and record keeping is in strict

adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTSMersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any


act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy


Liverpool Community Health NHS Trust

Records Policy Manual

Version 1.2.1May 2016 of 141

Version Number: 1.2.1

Ratified by: Records Management Sub Group

Date of Approval: Version 1.2.1, 16/05/2016

Name of originator/author: Admin, Records and Child Health Manager

Approving Body / Committee: Records Management Sub Group

Date issued (Current version): May 2016

Review date (Current Version): May 2017

Target Audience: All staff

Name of Lead Director / Managing Director:

Medical Director

Changes / Alterations Made To Previous Version:

1.2.1 Additional information in Record Policy, section 5.9, now includes expanded information regarding edit and deletion facilities in electronic health records and when to use them


Contents

Section1 Introduction

2 Purpose

3 Scope

4 Definitions

5 Roles and Responsibilities

6 Training

7 Equality Analysis

8 Audit

9 Associated Documentation

10 References

Appendices / ChaptersAppendix A Record Keeping and Management Policy – Page 10Appendix B Scanning Guidance and Image Quality Checking – Page 42Appendix C Tracking Tracing and Transfer Guidance – Page 70Appendix D Archiving Records Procedure – Page 79Appendix E Moving Guidance – Page 89

Appendix F Standardised Filing Guidance – Page 95Appendix G Corporate Records Management, Audit and Retentions- Page 100Appendix H Audit Procedure – Page 134

1. Introduction

Records, of any type, are an information asset because of their contents. Such information is only useful if it is correctly recorded, regularly updated and easily accessible when needed. Information is essential for the delivery of high quality evidence based health care, delivery of service and the organisation.

Principles of good documentation and health record keeping within clinical practice, ensures consistent standards for health record keeping for all staff across professional groups, employed by Liverpool Community Health NHS Trust (LCH), who are required to keep health records.

Records management is the process by which the organisation manages all aspects of information whether internally or externally generated and in any format or media type, from their creation, all the way through their lifecycle to their eventual disposal. LCH must comply with Information Governance Standards derived from legal and statutory obligations to create and maintain accurate records of all its activities.


2. Purpose

The purpose of this manual is to provide staff with guidance on processes regarding the following:

Record Keeping and Management Scanning and Quality Checking Transfer, Tracking and Tracing of Records Archive Corporate Records Management Audit

All documents within this manual are linked to the Records Keeping and Management Policy and therefore fall under its requirements for all LCH staff to comply with it.

3. Scope

This manual applies to all LCH staff who manage or handle health or corporate records.

4. Definitions

The following definitions have been identified in relation to this manual.

Abbreviations - An abbreviation is a short way of writing a word or a phrase that could also be written out in full, eg Dr instead of Doctor.Acronym - A word formed from the initial letters of a name, such as WIC for Walk In CentreAppraisal See disposal

Contemporaneous – As soon as possible after contact with the service user and within the same working day (Department of Health 1990).Corporate Records. Records (other than health records) that are of, or relating to, an organisation’s business activities covering all the functions, processes, activities and transactions of the organisation and of its employees. A document becomes a record when it has been finalised and become part of the organisation’s corporate information. At this point, the record must not be amended and should only be held in the corporate system, for example, the network drive or shared folder and not on a local drive on a personal computer or laptop.

Destruction - The process of eliminating or deleting records beyond any possible reconstruction.

Disposal - the implementation of appraisal and review decisions for the destruction, permanent preservation of records or the movement of records from one system to another


(for example, paper to electronic)1. This will be treated as appraisal within this document and is considered at all stages of the Records Management Lifecycle

Documentation – Includes all written or electronic information directly related to the care of a service user.

EHR – Electronic Health Record

Fraser Guidelines - The Fraser guidelines refer to the guidelines set out by Lord Fraser in his judgment of the Gillick case in the House of Lords (1985), which apply specifically to contraceptive advice:Gillick Competence – is a term originating in England and is used in medical law to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge

Health Record - A single record with a unique identifier containing information relating to the physical or mental health of a given patient who can be identified from that information and which has been recorded by, or on behalf of, a health professional, in connection with the care of that patient. This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the on-going care of the patient to whom it refers (Department of Health 2006).

Hybrid Record - A hybrid record is documentation of either an individual's health information, or Corporate Information that is in multiple formats and stored in multiple places, eg Paper and electronic.Information Governance (IG) a framework which allows organisations and individuals to ensure that personal and corporate information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care. It brings together all of the requirements, standards and best practice that apply to the handling of information.

Protective Marking Records should be marked to signify the nature of the contents and the level of security that should be applied to them.

NHS Confidential This is appropriate for documents and files containing person- identifiable or sensitive clinical or staff information.

NHS Private This applies to information that would need to be handled with care, and would be restricted from release to the general public or staff (if only for a limited period of time).

NHS Public These records are considered to be routinely made available to the public and staff.

Records Management Sub Group (RMSG) – A sub group of the Technology, Innovation & Information Group that meets on a bi-monthly basis. The Group is chaired by a clinician and contains representation from a wide variety of clinical groups and ‘clinical services’ administration managers.


5. Roles and Responsibilities

The following staff groups have been identified as having responsibilities in relation to this manual.

The Chief Executive is ultimately responsible for the content of all policies and their implementation.

Executive DirectorsResponsible for identifying, producing and for implementing Trust documents relevant to their area. They are also responsible for ensuring developments are made in accordance with this policy and produce procedures for the life cycle of records within their department.

Liverpool Community Health Board - The board is responsible for setting the strategic context in which organisational policies and procedures are developed, and for the formal review and approval of LCH policies.

Associate DirectorsAssociate Directors are responsible for management of records within their department(s). This includes:

Ensuring a review of compliance with this policy is undertaken

Put in place provision to ensure compliance with this policy if not already in place

4.1.5 Information Governance and Records ManagerDelegated responsibility to ensure that policies, procedures and guidance is in place, in line with legal requirements and best practice, to comply with IG related work areas including the management of all records. This includes:

Ensuring processes are in place to monitor compliance with records management standards

Promoting compliance with and awareness of this policy and supporting documents.

4.1.6 verpool Community Health NHS Trust Staff - It is the responsibility of all staff, including temporary, contractors, students and externally hosted staff to comply with this and other LCH policies. Compliance with LCH policies is a condition of employment and breach of a policy may result in action in accordance with LCH HR Policies.

4.1.7 Registered Professional Staff - As a registered professional accountability for the content and standard of health record keeping resides with the individual. They


are also accountable for the record keeping of non-registered staff to which they have delegated this duty as part of care provision.

A registered professional, should at all times follow the professional guidance issued by their regulatory body.

Everyone working for or with the NHS who records, handles, stores, or otherwise comes across information has a personal common law duty of confidentiality. The Data Protection Act 1998 now places statutory restrictions on the use of personal information, including health information. The Freedom of Information Act 2000 places statutory responsibility on individuals to follow the Trust’s policy and procedures to comply with the Act. For further information on this and other records management policies, please visit the information governance website at http://nww.liverpoolch.nhs.uk/LCHDepartments/Corporate_Services/Information_Ma nagement_and_Technology/Information_Governaance/Information_Governance_v3. aspx

Professionally registered staff are responsible for ensuring that any entries made by non-registered members of staff are of the required standard and they are also accountable for the consequences of these entries

Each Service / team must have a system in place that supports the professional staff member responsible for the care of the patient to ensure that the quality of care provided, and the documentation of the given care is of an acceptable standard. This should include discussion following interventions and any contacts with clients. Where there is any deviation from the normal or any concerns identified during client contact by non-registered staff, this must be discussed with the registered staff member responsible for the patient care. The Registered clinician is ultimately responsible for ensuring that appropriate action has taken place. The record must show evidence i.e. issues discussed and agreed action taken and an auditable trail that the Registered Clinician has reviewed and agreed to any deviation from the normal care plan.

4.1.8 Non-Registered Staff. Non-Registered staff must ensure that they record an accurate accounting of the intervention they are responsible for recording and that the intervention date and time is clearly stated. The non-registered staff member must sign and print their name in paper records after the entry and ensure that, if any deviation has been made to the treatment plan there is evidence that this has happened i.e. issues discussed and agreed action taken and the professionally registered clinician must then signoff that entry. For electronic records, the non- registered staff members entry will be clearly shown against their User Identification (user ID) and the registered clinician’s must have a separate entry immediately following the deviation clearly indicating their agreement to the revised plan. To be clear – the registered staff member should only sign off when a treatment has changed or deviated from the agreed plan. They should not sign off every entry unless there is a professional reason to do so.


4.1.9 ary or Agency Staff, Contractors, or Students - All other personnel will be expected to comply with the requirements of all relevant LCH Policies applicable to their area of operation

6. Training

Training related to all aspects of this manual is detailed within the Trust Training Needs Analysis and for Record Management elements can be sought from the Records Department

7. Equality Analysis

An equality analysis has been undertaken for the Records Keeping and Management Policy and a copy of this is retained by both the manual author and the Equality and Diversity Lead.

8. Audit

Audit of the information is on a 2 year cycle or as and when new national legislation or policy is created.

9. Associated Documentation

See appendices

10. References

NHS Health Record and Communication Practice Standards for Team Based Care 2004

Records Management: NHS Code of Practice. Department of Health Freedom of Information Act 2000 London: Stationery Office (FoIA 2000) Human Rights Act 1998, London: Stationery Office. Data Protection Act 1998 London: Stationery Office. (DPA 98) The Public Records Act 1958 London: Stationery Office. The Public Records Act 1958 (Admissibility of Electronic Copies of Public

Records) Order 2001 The Public Records Act 1967 London: Stationery Office. Access to Health Records Act 1990 London: Stationery Office. Setting the Record Straight 1995 Environmental Information Regulations 2004 NHS Information Governance Guidance on Legal and

Professional Obligations Information Governance Toolkit Care Quality Commission Standards NHS Litigation Authority Standards The National Archives, Records Management Standard BSI DISC PD0008 - 'Legal Admissibility and Evidential Weight of Information

Stored


BIP 10008:2014 legal admissibility and evidential weight of information stored electronically

ISO 15489 – 1:2001 Information and documentation – Records Management ISO 27001 International standard for Information Security Caldicott Review of Patient Identifiable Information (1 & 2) http://www.aomrc.org.uk/ Standards for the clinical structure and content

of patient recordsRelevant Legislation / Statutory Requirements / Government Documents

The principles of this policy are underpinned by the following statutory and NHS guidelines:-

The Nursing and Midwifery Council (2010) Guidelines for Records and Record Keeping. London

Standards of Conduct, Performance and Ethics (2003). Health Care Professionals Council

Records Management: NHS Code of Practice, Part 1 and Part 2 (2006) Department of Health

Gender Recognition Act 2004 Confidentiality: NHS Code of Practice 2003 Data Protection Act 1988 Freedom of Information Act 2000 Access to Health Records 1990 The Caldicott Committee: Report on the Review of Patient-identifiable

Information 1997 and 2013 The Victoria Climbie Inquiry Report – Chair Lord Laming (2003) Public Records Acts 1958 and 1967 Audit Commission, Setting the Record Straight 1995 NHS Health Record and Communication Practice Standards for Team Based

Care 2004. Human Rights Act 1998, London: Stationery Office. Environmental Information Regulations 2004 NHS Information Governance Guidance on Legal and

Professional Obligations Information Governance Toolkit Care Quality Commission Standards NHS Litigation Authority Standards The National Archives, Records Management Standard BSI DISC PD0008 - 'Legal Admissibility and Evidential Weight of Information

Stored BIP 10008:2014 legal admissibility and evidential weight of information stored

electronically ISO 15489 – 1:2001 Information and documentation – Records Management ISO 27001 International standard for Information Security


Appendix A


Policy for Record Keeping & Records Management

V1October 2015Page 11 of 141

Version Control

Version Number: 10.1

Ratified by: Technology, Innovation & Information Group

Date of Approval: (Original

Version)January 2009

Name of originator/author:

Admin, Records, Child Health & Domestic

Manager,

Deputy Records & Child Health Manager

Approving Body / Committee:Amendments approved by Information Governance Sub-Group

Date issued: (Current Version) Dec 2013August 2014

Review date: (Current Version) Dec 2014August 2016

Target audience: All Staff, Contractors, students within LCH.Name of Lead Director

/ Managing Director:Gary Andrews, Director of Finance and Commerce

Changes / Alterations Made To Previous Version (including date of changes)

Version 10.1 – Inclusion of equality analysis toolHybrid records and scanned documentation added.Some amendments to Core Record keeping standards.General flow of documentation and typographical amendments made

Consultation Records Management Sub Group

This policy should be read in conjunction with the following documents:

Records Management Strategy Retention, Storage and Destruction Policy. Protocol for the Management of the Records for Adopted Children. NHS Health Record and Communication Practice Standards for Team Based

Care 2004. Consent to Treatment Policy. Patient Identification Policy Transfer of Children’s Records Policy Information Governance Policy IG Guidance 05 - Tracking and Tracing Systems

V1 October 2015 Page 12 of 141

Section

Contents

Page1 Introduction 5

1.1 Status 51.2 Purpose 61.3 Aims 61.4 Scope 7

2 General Policy Statement 7

3 Definitions 7

4 Duties & Responsibilities 9

4.1 Duties within the Organisation 9

5 Process and Documentation 10

5.1 Purpose of Health Care Record 105.2 Hybrid Records 115.3 Core Health Record Keeping Standards 125.4 Essential Patient Demographics 125.5 Content and Style 135.6 Service User Held Record 145.7 Not to be included in Health Records 155.8 Third Party Information 155.9 Single/Electronic Records 155.10 Access to Health Records 155.11 Transfer of Health Records 155.12 Text Messaging 165.13 Inmate Health Records 16

6 Format of Records 16

7 Records Management Lifecycle 177.1 Creation 177.2 Naming and Filing Structure Guidance 187.3 Tracking and Tracing 187.4 Use of Records 187.5 Original Corporate Records 187.6 Finalised Corporate Documents 187.7 Copies of Records 187.8 Patient or Service User Held Clinical Records 197.9 Retention 197.10 Scanning 197.11 Appraisal 197.12 Additional Retention 197.13 Requires Permanent Preservation 207.14 Records Under a Request Process 207.15 Destruction of Records 20


8 Security of Records 20

9 Requests for Information 21

10 Records as Information Assets 21

11 Records Management Incidents 21

12 Training Requirements 21

13 Implementation, Monitoring and Review 22

14 Quality Impact Assessment 22

15 Support and Guidance 22

16 Compliance with Policy 22

17 Monitor and Review 22

18 Supporting Policies and Information 23

19 Relevant Legislation/Statutory Requirements/Government Documents 24

20 Appendixes 25

Appendix 1 Equality Analysis Appendix 2

AuditAppendix 3 Monitoring ToolAppendix 4 Professional Clinical Organisation Appendix 5 Links to LCH Approved Acronym List Appendix 6 LCH Services Record Format


1.0 IntroductionThe Health Service Commissioner states that failure in communication is the cause of most of the complaints received.

Records, of any type, are an information asset because of their contents. Such information is only useful if it is correctly recorded, regularly updated and easily accessible when needed. Information is essential for the delivery of high quality evidence based health care, delivery of service and the organisation.

Principles of good documentation and health record keeping within clinical practice, ensures consistent standards for health record keeping for all staff across professional groups, employed by Liverpool Community Health NHS Trust (LCH), who are required to keep health records.

Records management is the process by which the organisation manages all aspects of information whether internally or externally generated and in any format or media type, from their creation, all the way through their lifecycle to their eventual disposal. LCH must comply with Information Governance Standards derived from legal and statutory obligations to create and maintain accurate records of all its activities.

The organisation must comply with the Data Protection Act (1998), Freedom of Information Act (2000), Public Health Records Acts (1958 and 1967) and standards set by the Department of Health. This guidance includes Caldicott Guidelines in relation to the use of patient information and NHS codes of practice in relation to records management, confidentiality and information sharing and Information Security. Further details can be found within section 18 of the policy.

Records are an organisations memory, providing evidence of actions and decisions and representing a vital asset to support daily functions and operations. Records support policy formation and managerial decision-making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways.

It should be noted that this policy replaces all previous record keeping and record management policies

1.1 StatusThis is an Organisational wide policy.

It provides standards that will be adhered to by all Clinical & Corporate staff, across all professional groups who are working within LCH, who are required to keep records.

Persistent failure to comply with the requirements of this policy may lead to disciplinary action by the Trust, and / or reporting to the appropriate registration body.

This document should be read in-conjunction with guidelines issued by the appropriate professional regulatory authority, for example the Nursing and Midwifery Council (NMC) and Health & Care Professionals Council (HCPC) and any service specific guidelines. Please see Appendix 4 for links to some of the professional bodies that


staff within LCH may be affiliated to. Please be aware that this is not an exhaustive list and staff should refer to their own professional bodies.

1.2 PurposeThe purpose of this Policy is to provide guidance and clarity in the steps that must be taken to produce effective Records. This will ensure that:

This policy is designed to ensure we meet our legal obligations in relation to Records Management and to work within the wider framework of Information Governance (IG). The policy will set out expected standards, and reference appropriate guidance, where applicable, for staff to follow in relation to the management of all records, clinical and corporate. Where appropriate, staff will then develop service/system/departmental procedures and guidance to ensure that records are

Accurate and comprehensive information is available for the delivery of safe, high quality care

records can provide valuable information for teaching, research, and audit and as evidence in the event of a complaint or litigation

Local standards for health record keeping will facilitate the assessment, care, treatment and support of a service user.

An appropriate record of a professional intervention and outcome is a requirement of, and an indicator to, the standard of professional practice. “Good record keeping is a mark of a skilled and safe practitioner, whilst careless or incomplete record keeping often highlights wider problems with the individual’s practice” (NMC 2008).

Meet legal, operational and information needs

Readily accessible and available for use when needed to give a better use of staff time

Eventually archived or disposed

1.3 Aims

The aims of the policy are to ensure that records are:

available when needed so that events or activities can be followed through and reconstructed as necessary;

accessible, located and displayed in a way consistent with their initial use, with the original/current version being identified where multiple versions exist;

able to be interpreted and set in context: who created or added to the record and when, during which business process, and how the record is related to other records;

trustworthy and hold integrity, reliably recording the information that was used in, or created by, the business process;

maintained over time, irrespective of any changes of format so that they are available, accessible, able to be interpreted and trustworthy;

secure from unauthorised or inadvertent alteration or erasure, with access and disclosure being properly controlled and audit trails tracking use and changes;


shared, where appropriate, with other professionals in line with the Information Security Policy and Information Governance Policy, taking into account patients consent

held in a robust format which remains readable for as long as records are required;

retained and disposed of appropriately using documented retention and disposal procedures, which include provision for reviewing and permanently preserving records with particular archival value.

1.4 ScopeThis policy applies to all persons who are employed by, or act on behalf of LCH including both professional registered staff and non-registered staff, for example Health Care Assistants, Therapy Assistants and Students

Whilst this policy applies to Sexual Health Services within LCH, because of the sensitive nature of the work, clients will often provide false demographic details and the collection of full postal codes could conflict with the venereal diseases legislation. All staff within the sexual health services of LCH will be issued with local guidance on record keeping and should also refer to the Service Standards for Record Keeping issued by the Faculty of Family Planning and Reproductive Healthcare (2005)

2.0 General Policy Statements

LCH has developed this policy to provide local standards for records that support national policies and guidance and professional standards. LCH is committed to ensuring that all staff are trained and equipped to perform their role effectively. Each member of clinical staff is responsible for accessing the record standard training and for keeping themselves updated on any developments within record keeping, or changes to this policy, in-between the provided mandatory training sessions.

3.0 Definitions

Abbreviations - An abbreviation is a short way of writing a word or a phrase that could also be written out in full, eg Dr instead of Doctor.Acronym - A word formed from the initial letters of a name, such as WIC for Walk In Centre

Appraisal See disposal

Contemporaneous – As soon as possible after contact with the service user and within the same working day (Department of Health 1990).

Corporate Records. Records (other than health records) that are of, or relating to, an organisation’s business activities covering all the functions, processes, activities and transactions of the organisation and of its employees. A document becomes a record when it has been finalised and become part of the organisation’s corporate information. At this point, the record must not be amended and should only be held in the corporate system, for example, the network drive or shared folder and not on a local drive on a personal computer or laptop.


Destruction - The process of eliminating or deleting records beyond any possible reconstruction.

Disposal - the implementation of appraisal and review decisions for the destruction, permanent preservation of records or the movement of records from one system to another (for example, paper to electronic)2. This will be treated as appraisal within this document and is considered at all stages of the Records Management Lifecycle

Documentation – Includes all written or electronic information directly related to the care of a service user.

EHR – Electronic Health Record

Fraser Guidelines - The Fraser guidelines refer to the guidelines set out by Lord Fraser in his judgment of the Gillick case in the House of Lords (1985), which apply specifically to contraceptive advice:

Gillick Competence – is a term originating in England and is used in medical law to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge

Health Record - A single record with a unique identifier containing information relating to the physical or mental health of a given patient who can be identified from that information and which has been recorded by, or on behalf of, a health professional, in connection with the care of that patient. This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the on-going care of the patient to whom it refers (Department of Health 2006).

Hybrid Record - A hybrid record is documentation of either an individual's health information, or Corporate Information that is in multiple formats and stored in multiple places, eg Paper and electronic.

Information Governance (IG) a framework which allows organisations and individuals to ensure that personal and corporate information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care. It brings together all of the requirements, standards and best practice that apply to the handling of information.

Protective Marking Records should be marked to signify the nature of the contents and the level of security that should be applied to them.

NHS Confidential This is appropriate for documents and files containing person-identifiable or sensitive clinical or staff information.

NHS Private This applies to information that would need to be handled with care, and would be restricted from release to the general public or staff (if only for a limited period of time).

NHS Public These records are considered to be routinely made available to the public and staff.


Records Management Sub Group (RMSG) – A sub group of the Technology, Innovation & Information Group that meets on a bi-monthly basis. The Group is chaired by a clinician and contains representation from a wide variety of clinical groups and ‘clinical services’ administration managers.

4.1 Duties and Responsibilities

This section of the document provides an overview of the individual, document development. Departmental and committee duties. This includes the levels of responsibility for the policy.

4.2 Duties within the Organisation4.2.1 Chief Executive The Chief Executive is ultimately responsible for the content of all policies and their implementation.4.2.2Executive DirectorsResponsible for identifying, producing and for implementing Trust documents relevant to their area. They are also responsible for ensuring developments are made in accordance with this policy and produce procedures for the life cycle of records within their department.

4.2.3 verpool Community Health Board - The board is responsible for setting the strategic context in which organisational policies and procedures are developed, and for the formal review and approval of LCH policies.4.2.4 ds of Department responsibilityHeads of department are responsible for management of records within their department(s). This includes:



4.2.5 ds, Childs Health & Admin ManagerDelegated responsibility to ensure that policies, procedures and guidance is in place, in line with legal requirements and best practice, to comply with IG related work areas including the management of all records. This includes:





4.2.7 Registered Professional Staff - As a registered professional accountability for the content and standard of health record keeping resides with the individual. They are also accountable for the record keeping of non-registered staff to which they have delegated this duty as part of care provision.

A registered professional, should at all times follow the professional guidance issued by their regulatory body.

Everyone working for or with the NHS who records, handles, stores, or otherwise comes across information has a personal common law duty of confidentiality. The Data Protection Act 1998 now places statutory restrictions on the use of personal information, including health information. The Freedom of Information Act 2000 places statutory responsibility on individuals to follow the Trust’s policy and procedures to comply with the Act. For further information on this and other records management policies, please visit the information governance website at http://nww.liverpoolch.nhs.uk/LCHDepartments/Corporate_Services/Information_Mana gement_and_Technology/Information_Governaance/Information_Governance_v3.asp x

Professionally registered staff are responsible for ensuring that any entries made by non-registered members of staff are of the required standard and they are also accountable for the consequences of these entries

Each Service / team must have a system in place that supports the professional staff member responsible for the care of the patient to ensure that the quality of care provided, and the documentation of the given care is of an acceptable standard. This should include discussion following interventions and any contacts with clients. Where there is any deviation from the normal or any concerns identified during client contact by non-registered staff, this must be discussed with the registered staff member responsible for the patient care. The Registered clinician is ultimately responsible for ensuring that appropriate action has taken place. The record must show evidence i.e. issues discussed and agreed action taken and an auditable trail that the Registered Clinician has reviewed and agreed to any deviation from the normal care plan.

4.2.8 Non-Registered Staff. Non-Registered staff must ensure that they record an accurate accounting of the intervention they are responsible for recording and that the intervention date and time is clearly stated. The non-registered staff member must sign and print their name in paper records after the entry and ensure that, if any deviation has been made to the treatment plan there is evidence that this has happened i.e. issues discussed and agreed action taken and the professionally registered clinician must then signoff that entry. For electronic records, the non- registered staff members entry will be clearly shown against their User Identification (user ID) and the registered clinician’s must have a separate entry immediately following the deviation clearly indicating their agreement to the revised plan. To be clear – the registered staff member should only sign off when a treatment has changed or deviated from the agreed plan. They should not sign off every entry unless there is a professional reason to do so.



5. Process and Documentation of Health Records

5.1 Purpose of Health RecordsHealth records allow professional registered staff and non-registered staff to account for the care that they have delivered. Health records enhance communication between care team members, service users and carers. A good health record promotes continuity of care for the service user. Comprehensive and accurate records are essential tools when a member of staff is called to account for the care that has been given.

The main purposes of keeping service user records are:- To form a basis for planning service user’s care and treatment, obtaining

feedback on their progress and suggesting actions to improve a service user’s health status.

To support continuity of care amongst all agencies involved in the delivery of care to a service user and provide written evidence of the service delivered.

To meet legal, professional and access requirements. Health Records provide the basis for court report writing and as such should contain all relevant information.

To provide information for clinical management, resource management, self- assessment, clinical audit, quality assurance and research.

To provide proof of consent obtained to treat service use and to share information relating to the care of the service user.

5.2Hybrid RecordsA hybrid record is a record that includes both paper and electronic documents, and uses both manual and electronic processes to access information.

5.2.1. ealthFor example in Health Records there may be lab, x-ray results or appointment details available electronically, whereas SAP’s, care plans, provider information, and referrals remain on paper. Other health information may be maintained on various other media types such as film, video, or an imaging system.Professionals may be using an electronic clinical system which has templates set up to record clinical observations, contacts, care plans. They may also still have a paper record that they keep for collating correspondence, notes from other professionals or non templates activity. As the majority of services use at least one electronic system to record contact information all LCH health records would be deemed hybrid. Staff must therefore always check both paper and electronic.. The Data Protection Act is very specific on duplication and excessive data. Whilst the transition to a full EHR is ongoing staff should record clinical information into the paper record and record KPI information eg Contacts, FRAT & MUST into the electronic system until such time as Mobile solution or full electronic solution is available. Ideally a reference to the other recording should be made i.e. paper record stating please also see EMIS. Once the electronic system is fully available in the community the paper input will be replaced by electronic recording...


Whilst a mobile solution is not available staff may need to note down information for inputting when back at a base. This is acceptable to do as long as it does not contravene the LCH Diary guidance or would not cause harm if lost i.e. cannot be fully identifiable if lost. This information must be inputted exactly onto the system and then destroyed. Otherwise it will become a patient record and must be retained in accordance with retention periods.

5.2.2 Corporate RecordsAn example for Corporate Records would be an order is recorded on the Finance electronic system but the actual invoice from the organisation is retained in paper format.The Data Protection Act equally applies to these records as to those indicated in 5.2.1 above.

5.3 Core Health Record Keeping Standards All hand-written entries to the health record will be made in permanent

black ink. All entries will be legible All entries will be dated using format dd/mm/yyyy All entries will be timed using the 24-hour clock All entries will be signed (either via electronic User ID or physical) If using a form and space only for initials then the form must have a section

whereby each initial is identified and signed off On each page of the health record that a practitioner makes an entry, there

will be a least one signature that has the practitioner’s printed name and designation with it.

All LCH Staff (as identified in 4.1.6) present at the time of patient/client interaction should be recorded into the Health Record as either present or participating in the interaction. Their name and designation should be recorded. This is recordable in both paper and electronic records.

All entries will be recorded contemporaneously All entries will be recorded chronologically The time of the service user contact or other action or communication, such

as telephone conversation or text message, will be included in the entry if this is different than the time the entry to the health record is made

Correction fluid / white out fluid will not be used Mistakes will be crossed out using a single black line that does not obscure

the initial entry. The crossed out entry will be signed, dated and timed by the practitioner

All entries will be recorded in full. Abbreviations will not be used unless they have been approved by the Records Management Sub Group (RMSG) and have been incorporated on to the Service Specific Abbreviation List. A copy of which must be included within each physical record.

All entries will be made sequentially without gaps. Any gaps that are unavoidable, for example when a temporary file has been used, should be crossed through to avoid the recording of information out of order


Each page of the physical health record will contain the service user’s name and reference number either NHS number, system number or the name and date of birth as a minimum

In sexual health services the specific clinic number should be used on each page if the date of birth or NHS number is not available or reliable

Electronic records should be inputted using the standards above, i.e. timed, dated, contemporaneous, factual etc. Additionally any electronic systems should be able to be audited to account who has entered each entry, when it was entered etc

Each clinical entry should be able to be identified as a separate entry within an episode of care

5.3.1 Scanned DocumentsAny document that is scanned needs to follow the LCH Scanned Document Policy (to be issued 2014). This policy supports the BSI 20008 that confirms that documentation is legally admissible.If amendments to a scanned document (either via printing and writing or electronically noting) requires the amendment to be classified as an additional document (separate to the originally scanned document) and therefore will require scanning and adding to the folder.5.4 Essential Patient Demographics.Each health care record will contain a System generated Front Sheet at the start of the record that includes the service agreed information. If no system generated sheet available the agreed (via RMSG) front sheet documentation will be populated by the primary clinician. This will contain as a minimum:-

Full name of the service user A unique number to identify the service user. This will be their NHS number

if provided or traceable. If NHS number not available the service number (e.g. system generated unique reference number) will be used

Date of birth of the service user in DD/MM/YYYY format Ethnicity of service user – this should be recorded using the National ethnicity

codes and should be stated by the Service User Gender – as the patient wishes to portray themself Full address, including full post code, of the service user Telephone contact number for the service user, if available Contact name, address and telephone number of the person to contact in

the event of the emergency – for relevant services (i.e. not applicable for sexual health). Ideally this will be the service user’s next of kin

Name, address and telephone number of the service user’s General Practitioner

Any alert information such as drug reactions, allergies and caring responsibilities

Preferred Communication Language Preferred Place of Death (for relevant Services) Actual Place of Death (for relevant Services)

The Equality and Human Rights Act (2010) puts a legal duty on all public sector organisations to collect information relating to a persons protected equality


characteristics which are, age, disability, gender, religion or belief, sexual orientation and race. If the system that staff are using collects this information then it is essential patient demographics - not just ethnicity or gender. There are Trust approved monitoring forms that must be used and any change must be approved by the Equality& Patient Experience Manager

Each service may wish to include additional information, for example the school that a child attends. Service leads for each service will agree any additional information

5.5 Content and StyleAll records will (be): Started at initial contact with the service user Factual, consistent and accurate Written contemporaneously Free from jargon, abbreviations (unless agreed via RMSG), meaningless

phrases and irrelevant speculation Free from derogatory and judgemental comments Free from subjective opinion, unless used as part of a specific recording

system such as reported, observed, assessment and plan (R.O.A.P.) or subjective, objective assessment and plan (S.O.A.P.)

Written, where possible with the involvement of the service user and/or the carer, but with due regard to confidentiality

Written in a way that can be understood by the service user Contain a detailed service user history Provide evidence of the assessment, identified risks, care planned, risk

management plans, decisions made, reasons for decisions taken, care delivered, patient response and evaluation of care

Provide evidence ofValid consent for examination or treatment, as per LCH Consent Policy

Provide evidence of refusal of consent Be free from 3rd Party references if not relevant to care of service user. If

unavailable, it should be noted that this information will be removed under a Subject Access request by the Service User. If patient held record then 3rd party information should only be noted if given by the Service User and the source should be clearly documented

For children the record should contain, for the purposes of consent, information on the persons having parental responsibility for the child or evidence that the child is “Gilllick competent”

State reasons for any diagnostic tests ordered or undertaken (e.g. blood tests) Contain any diagnostic test results, accompanied by a dated and timed

signature and printed name, to indicate that they have been seen Contain information on any actions / decisions taken following the results of

any diagnostic tests Contain written details of any verbal instructions / advice given to service users

or their carers Contain a record of any encounters and interventions with the resulting outcome,

relating to the service user, including those when a service user has not been directly involved, such as telephone calls, conversations or text messages with relatives or other professionals. Include a note of any factors that appear to affect


the service user, including risks, warnings, crisis management plans and / or possible risks to others

Include clearly visible information on any known drug reactions or allergies Record anything relevant that has been said to you using quotation marks with the

name and designation of the person that made the comment Contain correspondence, including any emailed communications

or correspondence For safeguarding children cases the record should contain letters from local

authority solicitors and other legal information should be included in the records, for example copies of contact orders, residence orders and specific issues orders. These documents are required as they may determine the care provided and who has / does not have parental responsibility

5.6 Service User Held RecordsService specific guidance should exist where service user (patient) held records are used / required. Service specific guidance on service user held records should include guidance on the following issues:

Rationale. Procedures to be followed. Confidentiality. Audit. Procedures for recalling the record. Requirements for data collection. Use of supplementary files. A supplementary file may be used when there is an

issue of concern, such as fabricated illness or abuse, which would increase the risk of harm to the patient / client if recorded in a patient held record. The use of supplementary files should be included in service specific guidance.

5.7 Not to be included in Health RecordsHealth Records should NOT contain the following:

Offensive comments or irrelevant speculation about the service user or their carer

Derogatory or judgemental comments Meaningless phrases, unapproved or unnecessary abbreviations or jargon Irrelevant personal opinions regarding the service user Complaint correspondence, investigations, or any associated documentation. Litigation correspondence, letters to the Trust’s Complaints Manager or any

associated documentation. Any litigation or complaint correspondence should be held in a separate file by the Complaints Department

5.8 Third Party InformationThird party information must be contained within a separate section of the record to facilitate withholding this during any disclosure / access requests. This will include carer assessments, carer care plans and contacts relating to the carer in their own right. This may also be information disclosed under safeguarding process.. As such, the service user would not have access to it without the express written consent of the provider of the information. Some third party information may be collected as part of


the medical, family and sexual history taking process. Whilst it is acceptable to record some third party information in this context, services and practitioners need to be aware that this information will need to be removed should the record be requested.

5.9 Single / Electronic RecordsA recommendation from The Climbie Inquiry HC570 (2003) stated that information within an agency / organisation about a patient / client should be brought together within a single record for the patient / client. Full use should be made of electronic records where available and when agreed by service leads. Where electronic records are available, the full function should be utilised, this includes the use of decision algorithms as these provide evidence of the decision making process and other evidence for audit. Care should be taken to reduce any duplication between electronic and paper records whilst they are both in use.

The same standards and procedures apply to electronic records as to paper, i.e. all entries must be contemporaneous and a log of the person who entered the information in to the record, the date and time entered must be kept. Electronic records will be audited for the same data items as paper.

If an entry in a patient's record (be that an electronic or paper record) requires editing, it should normally only be edited by the person who originally input the entry. The entry should make it clear:- What is being edited/changed- Why it was edited- Date and time of the change- Name if person making the change

I. Deletion of records versus editing - Any deletion to an electronic record should only ever be made once approved by a clinical team leader and only when editing the record will not suffice and must be recorded via the correct coded template for reporting and audit purposes; for paper records words or phrases can be scored through, but not actually deleted from the record (or scribbled out if it is a paper record).

II. Deletion of records versus editing - If circumstances arise whereby the registered or non-registered staff member is no longer employed by LCH and an entry requires editing due to inaccuracies, the person adding the additional note/making the change is required to seek approval from a senior member of their team or service before any alterations are performed, and the name of this person should also be included with the changes in the record. Do not alter or edit a record without this prior authorisation.

III. Deletion of records versus editing - Deletion In the rare occurrence when a record has been added incorrectly and needs to be removed, this must only be undertaken by a clinical team leader with a clear audit trail, including submission of an incident on Datix (as such occurrences are usually only required to address an issue related to an Information Governance error or breach).

If the reason for the deletion/editing of record (electronic or paper) is not made


absolutely clear (name, date, time, reason, etc.) then the changes may be interpreted as an attempt to falsify the record and appropriate disciplinary action may ensue

5.10 Access to Health RecordsThere are various requirements and legislation related to access to health records. For the local policy and Caldicott principles please see the Information Governance pages on LCH intranet site.

5.11 Transfer of Health Records

A Tracking and Tracing guidance is available to support the transfer/ movement of health records. This is available on the Records Policies page of LCH intranet site.

If an individual patient/user is transferring out of the care of the LCH a copy of the record should be sent to the new provider of care once consent is obtained from the patient/user or parent/guardian (in the case of child).

There are specific requirements for transferring the records of children who are on the Child Protection Register, are Looked After Children and any other records that the clinician decides requires safe secure transmission. Information on this procedure can be found in LCH safeguarding children procedures and the Policy for the Transfer of Children’s Records.

If a whole service is transferring out of LCH please refer to the Best Practice Guidance re transfer of service.

5.12 Text MessagingText messaging is in use within LCH primarily for communicating appointment messages or reminders. Some services have agreed that they will use text messages to inform patients / clients of results of tests as part of a screening programme e.g. chlamydia screening programmes. There are specific guidance within the relevant services for these and they should be referred to before any such messages are sent.

5.13 Inmate Health RecordsInmate Health Records post April 2006 are the property of the provider of health care. For prisons within the responsibility of Liverpool Community Health these records should be used, written and maintained as per this policy. Records prior to April 2006 are the responsibility of National Offender Management Service (NOMS) and should be kept in accordance with their policy, guidance and regulations.

6. Format of Records

This policy applies to any clinical or corporate record, regardless of media type it is stored on, some examples are included below, but are not limited to the following:

patient health records (electronic or paper based)

administrative records (including, for example, personnel, estates, financial)


X-ray and imaging reports, output and images;

photographs, slides, and other images;

microform (i.e. microfiche/microfilm);

audio and video tapes, cassettes, CD-ROM etc;

e-mails (both outgoing and incoming responses);

computerised records;

scanned records;

text messages (both outgoing and incoming responses).

mobile storage device eg Pen drive

Further clarification on accepted storage devices should be obtained via Information Security Policy which is available on the LCH Intranet site.

7. Records Management Lifecycle

This section will set out the minimum expectations for services to ensure compliance with the management of records from creation to disposal or preservation, also known as the Records Management Lifecycle. (See figure 1 below)

Figure 1

7.1 Creation

Record creation is one of the most important processes in records management and should be captured or filed into a filing system to suit the specific service.

Each service should develop a process that ensures:

Records are held on a media that will be durable and last until its specified retention period.

o Manual records should have secure fastening e.g. treasury, ring binders etc.

Clear naming structure

Clear filing structure to the record with an index; with precise instructions for the location of documents in each section and that they should be held in chronological order; to facilitate easy entry and retrieval of information.


Use of unique reference to be applied to all records; current and future records relevant to the type of record they are for example, but not limited to:

o Staff Assignment number for human resource records

o NHS Number for health records. Some services such as, but not limited to, Asylum, Prison and Sexual Health services have specific exemptions to the use of the NHS Number but a unique reference must still be generated.

Records are to be kept in their context and be classified using the protective marking scheme, and stored securely relative to the marking applied.

Allow a tracking and tracing system to be used

7.2 Naming and filing structure guidance

Specific guidance on naming and filing structures of corporate records is available on the intranet. Guidance of Health Record Standards is contained in section 5 of this policy.

7.3 Tracking and Tracing

Tracking and tracing procedures must be in place within each department/service that enables the movement and location of records to be controlled and provide an auditable trail of record movement. Systems may vary depending on operational need but should include:

the item reference number or identifier;

a description of the item (for example the file title);

the person, position or operational area having possession of the item;

the date of movement.

The system adopted should maintain control of the issue of records, the transfer of records between persons or operational areas, and return of records to their home location for storage. The simple marking of a file to indicate to whom the file is being sent is not in itself a sufficient safeguard against files being lost.

Specific guidance on these processes is contained in IG Guidance 05, Tracking and Tracing Systems, available on the LCH Intranet site.

7.4 4 Use of Records

Within each service the use of records will vary dependant on the nature of the service and the purpose of the record, however some key policy requirements are established below.

7.5 Original Corporate Records

The use of any original corporate records within a service should be controlled, and only those authorised to make additions, alterations or close/finalise records should be able to do so. For example when a draft policy is approved.


7.6 Finalised Corporate Documents

The use and distribution of finalised corporate records should be controlled in line with the protective marking and read only copies be made available. The original must be kept by owner of the document. Only the original document and its versions are the corporate record.

7.7 Copies of Records

Any record that is copied or printed from an electronic or manual record should be marked as such as it is not the original record. It should be given the same security provisions and restrictions on disclosure as the original record.

If a copy of a record is altered or annotated in any way it then becomes new record, and must follow its own records lifecycle.

7.8 Patient or Service User Held Clinical Records

Service specific guidance should exist where service user (patient) held records are used / required. The service specific guidance should include:

Procedures to be followed for management and access to records Explaining to the individual their roles and responsibilities How and where information will be held with the individual patient or

service user The use of supplementary files held elsewhere and how the master copy will

be established when both files are closed.

The principles within duplicate records and copies of records must be incorporated in the guidance.

7.9 Retention

Once a document is no longer in use or active, it must then be stored and retained in line with NHS Records Management Code of Practice. This specifies how and how long each type of record has to be kept for (retention schedules) in line with national guidance. Locally agreed retention periods, which are contained within the guidance, have been established where no national standards have been set. These have been agreed via the RMSG. This guidance should be followed as part of this policy.

Retention periods are calculated using a calendar year approach i.e. if an District Nurse episode was closed in 2000 it would be eligible for destruction in 2008 (i.e. after an 8 year retention period).

7.10 Scanning

Manual records can be held in alternative formats which will involve scanning which must meet national standards to ensure the legal admissibility of electronic documents. For further information please refer to the Scanning Guidance on the Policies Records page of LCH Intranet.

7.11 Appraisal


Before a record is created, during its use and throughout its retention it must be appraised to identify its status, format, retention, purpose and type throughout the Records Management Lifecycle to ensure it is appropriate.

Once a record has reached its retention period it should be appraised to identify if it needs to be kept for longer, transferred elsewhere or can proceed to be destroyed.

Each service is responsible for organising periodic checks of their Services’ records to identify those that have reached their specified retention period and manage them accordingly.

7.12 Additional retention

In certain circumstances it may be decided that an individual’s record, or specific type of record may need to be kept for longer than specified within the Records Retention Period. This should be agreed following the process within the Records Retention Period Guidance document.

Decisions to extend retention periods must be clearly documented, an understandable rationale provided and new retention period established.

Where a specific type of record has its retention period extended this should be updated within the guidance document.

7.13 Requires permanent preservation

Certain records may be of significant public interest, and require permanent preservation by the Public Records Office. Records selected for archival preservation should be discussed with the Records Management Team.

7.14 Records under a request process

When records have been requested under legislation and/or part of an on-going complaint, incident investigation or litigation, the information should be kept for the longest relevant retention period after the closure of the request.

7.15 Destruction of Records

Once a record has reached its retention period, and it has been appraised as no longer being required it can be destroyed, which is an irreversible act. As many records contain sensitive and/or confidential information and their destruction must be undertaken securely. The method of record destruction must meet the standards set out within the Information Security Policy to provide adequate safeguards against the accidental loss or disclosure of the contents of the records.

When destroying records the following must be done:

A list of records being destroyed must be kept. This should show their reference, description and date of destruction. (Disposal schedules would constitute the basis of such a record.)

Certification should be received and kept as proof of destruction. If contractors are used, they should be required to sign confidentiality undertakings and to produce written certification as proof of destruction.

At no time should records be left unsecured whilst awaiting destruction


If using internal destruction process this must be by cross cut shredder

8. Security of Records

Throughout the Information Lifecycle records should be kept secure, in line with the Information Security Policy, and only accessed by appropriate persons. The level of security will depend on the protective marking/classification of documents.

NHS Public Records should be controlled whilst being developed, but once made available to the public, security controls need not be significant.

NHS Confidential and NHS Private Records should be secure at all stages of the Records Lifecycle. To do this the following should be in place:

Access and disclosure should be properly controlled in line with the tracking and tracing requirements

Records should be secure from unauthorised or inadvertent access or alterations. Audit trails must be in place to track the use and changes

Assignment of responsibilities to protect records from loss or damage over time.

The accommodation should also have proper environmental controls and adequate protection against fire and flood.

Records should be stored in a secure location when not in use, e.g. lockable filing cabinets/cupboards, rooms locked within an alarmed building, when out of normal working hours.

If records are not able to returned to an LCH building overnight/weekend they must be kept in line with the LCH Records Tracking and Tracing Guidance

NHS Confidential information should only be disclosed if it complies with the LCH Confidentiality and Information Sharing Policy, Information Security Policy and supplementary guidance

Ensuring that records are transported in a secure and confidential manner. Whoever transports the records from one site to another should be contractually bound to comply with the necessary requirements and follow the Safe Haven (Secure) Transfers of Information guidance.

9. Requests for Information

There are many legal requirements governing access for information. If a request is made from an external source for information these should be directed to the Information Governance Team.

10. Records as Information Assets


In line with the Information Security Policy, all information will be seen as an asset and require registration and assessment of appropriate risks. Directors will be required to ensure each service maintains the information asset register to include stores of health and corporate records.

For more information see the Information Security Policy and supporting guidance.

11. Records Management Incidents

The permanent or temporary loss or unavailability of a record or records should be seen as an incident, in line with the Information Security Policy and reported.

Please see the Policy for the Management of Incidents (Including Serious Untoward Incidents) and supporting guidance for more information.

12. Training Requirements

For training to support the implementation of this Policy, please refer to the Training Needs Analysis found on the LCH website.

13. Implementation, Monitoring and Review

Compliance to the policy should be noted as a key performance indicator for every member of staff involved in direct care delivery (excluding General Practitioners and Dentists), at yearly personal development planning and case / clinical supervision for child and adult protection. This is appropriate as careless or incomplete record keeping often highlights wider problems with professional practice (NMC 2005). When any individual or team does not achieve compliance to the policy, line managers / service leads should implement appropriate measures to support the achievement of the required standard.

14. Quality Impact Assessment

This has been undertaken and the evidence has been retained by both the author and Equality & Diversity Lead of LCH.

15. Support and guidance

The Records Management Team will provide guidance documents to supplement this policy as necessary to assist staff with clear expectations in relation to expected records practices. These should be seen as an extension of this policy.

16. Compliance with Policy

Compliance against this policy will be driven through the collection of evidence for the relevant IG Toolkit, records standards audits and Care Quality Commissioning assessments and Audits. This will be reviewed along with other compliance measures through the relevant committees.


Should anyone believe that it is not possible to meet the requirements within this policy and associated guidelines this must be brought to the attention of the departments’ manager and discussed with the Records Management Team. Any issues will need to be documented as a risk and in conjunction with the Records Management team the service must put in place an action plan to make necessary improvements.

Failure to comply with the requirements of this policy and underpinning guidance will be seen as an incident and upon investigation may lead to disciplinary and/or legal action in line with HR policies and procedures by the Trust. This may also require external reporting i.e. to professional bodies.

17. Monitor and Review

As part of Information Asset identification (section 9), services will be required to identify the appropriate controls and assurance linked to this policy. Review of the documented assets will provide a baseline to provide additional support and guidance.

Progress monitoring on policy implementation will be fed into the appropriate committee structures as appropriate to provide assurance to the Integrated Governance Committee.

A regular assessment of Records Management practices will be put in place to:

identify areas of operation that are covered by the Trust’s policies and identify which procedures and/or guidance should comply with the policy

set and maintain standards by implementing new procedures, including obtaining feedback where the procedures do not match the desired levels of performance

highlight where non-conformance to the procedures is occurring and suggest a tightening of controls and adjustment to related procedures

This review will be led by the Records Management Team in conjunction with the Data Quality Team but may be linked into exiting review arrangements within services. The results will be reported to relevant directors and committees within the organisation.

This policy will be reviewed every 3 years or sooner if new legislation, codes of practice or national standards are to be introduced.

18 Supporting Policies and Information.

Records Management Strategy Retention, Storage and Destruction Policy Protocol for the Management of the Records for Adopted Children Consent to Treatment Policy Patient Identification Policy Transfer of Children’s Records Policy Information Governance Policy


Approved Service Specific Abbreviations List NHS Health Record and Communication Practice Standards for Team

Based Care 2004 Records Management: NHS Code of Practice. Department of Health Freedom of Information Act 2000 London: Stationery Office (FoIA 2000) Human Rights Act 1998, London: Stationery Office. Data Protection Act 1998 London: Stationery Office. (DPA 98) The Public Records Act 1958 London: Stationery Office. The Public Records Act 1958 (Admissibility of Electronic Copies of

Public Records) Order 2001 The Public Records Act 1967 London: Stationery Office. Access to Health Records Act 1990 London: Stationery Office. Setting the Record Straight 1995 Environmental Information Regulations 2004 NHS Information Governance Guidance on Legal and Professional Obligations Information Governance Toolkit Care Quality Commission Standards NHS Litigation Authority Standards The National Archives, Records Management Standard BSI DISC PD0008 - 'Legal Admissibility and Evidential Weight of Information

Stored BIP 0008-1:2004 legal admissibility and evidential weight of information

stored electronically ISO 15489 – 1:2001 Information and documentation – Records Management ISO 27001 International standard for Information Security Caldicott Review of Patient Identifiable Information (1 & 2) http://www.aomrc.org.uk/ Standards for the clinical structure and content

of patient records

19 Relevant Legislation / Statutory Requirements / Government Documents

The principles of this policy are underpinned by the following statutory and NHS guidelines:-

The Nursing and Midwifery Council (2010) Guidelines for Records and Record Keeping. London

Standards of Conduct, Performance and Ethics (2003). Health Care Professionals Council

Records Management: NHS Code of Practice, Part 1 and Part 2 (2006) Department of Health

Gender Recognition Act 2004 Confidentiality: NHS Code of Practice 2003 Data Protection Act 1988 Freedom of Information Act 2000 Access to Health Records 1990 The Caldicott Committee: Report on the Review of Patient-identifiable

Information 1997 and 2013 The Victoria Climbie Inquiry Report – Chair Lord Laming (2003)


Public Records Acts 1958 and 1967 Audit Commission, Setting the Record Straight 1995 NHS Health Record and Communication Practice Standards for Team Based

Care 2004. Human Rights Act 1998, London: Stationery Office. Environmental Information Regulations 2004 NHS Information Governance Guidance on Legal and Professional

Obligations Information Governance Toolkit Care Quality Commission Standards NHS Litigation Authority Standards The National Archives, Records Management Standard BSI DISC PD0008 - 'Legal Admissibility and Evidential Weight of Information

Stored BIP 0008-1:2004 legal admissibility and evidential weight of information stored

electronically ISO 15489 – 1:2001 Information and documentation – Records Management ISO 27001 International standard for Information Security


Equality Analysis

Policy Name: Record Keeping & Management PolicyRatification Committee / Group: Records Management Sub GroupWhat inequalities in access, experience or outcomes have been identified in relation to each of the protected characteristics (race, gender, age, disability, sexual orientation, religion and belief, gender reassignment, pregnancy and maternity)?

None, the purpose of this policy is to maintain records in compliance with• Records Management: NHS Code of Practice. Department of Health• Freedom of Information Act 2000 London: Stationery Office (FoIA 2000)• Human Rights Act 1998, London: Stationery Office.• Data Protection Act 1998 London: Stationery Office. (DPA 98)• The Public Records Act 1958 London: Stationery Office.• The Public Records Act 1958 (Admissibility of Electronic Copies of Public Records) Order 2001• The Public Records Act 1967 London: Stationery Office.• Access to Health Records Act 1990 London: Stationery Office.• Setting the Record Straight 1995• Environmental Information Regulations 2004• NHS Information Governance Guidance on Legal and Professional Obligations• Information Governance Toolkit• Care Quality Commission Standards• NHS Litigation Authority Standards• The National Archives, Records Management Standard

What qualitative or quantitative evidence have you used in your analysis?

Standards are set for Records by numerous laws, legislation and policies this has provided the qualitative and quantitative evidence.

What stakeholders (including patients or voluntary organisations) have you consulted with?

All information has been consulted against Royal College Standards

What actions need to be taken to minimise any issues you have identified?

N/A

Audit


A comprehensive Clinical Records Audit is undertaken the Clinical Governance Team on an annual basis. A comprehensive records management and keeping audit is completed on a rolling schedule. Please refer to LCH Record Keeping Audit Process

Questions for the audit are updated regularly to reflect changes in legislation and practice and are in line with the Information Governance Toolkit.

The audit will review paper, scanned and electronic records for both Corporate and Health Records.

Results are collated and a report is presented via RMSG to TII Group. Results are RAG rated against both national requirements and local targets and any Red or Amber results are discussed with service leads and action plans agreed. Action plans are then presented to the RMSG for approval and are monitored at the group to ensure progress. Interim/Dip Tests are performed to also ensure compliance and progress.


Monitoring ToolMinimum requirement to be monitored

Process for monitoringe.g. audit

Responsible individual/ group/ committee

Frequency of monitoring

Responsible individual/ group/ committee for review of results

Responsible individual/ group/ committee fordevelopment of action plan

Responsible individual/group/ committee for monitoring of action plan andImplementation

a. Basic record keeping standards which must be used by all staff

Audit RMSG Annual RMSG IG and Records Manager

RMSGTII Group

b. Process for making sure that contemporaneous record of care is completed

Audit RMSG Annual RMSG IG and Records Manager

RMSGTII Group

c. how organisation trains staff in line with training needs analysis

TNA RMSG Annual RMSG IG and Records Manager

RMSGTII Group


Professional Clinical Organisations (Please note that this list is not exhaustive and staff must refer to their own clinical organisations guidelines):-

www.nmc-uk.org www.csp.org.uk www.cot.co.uk/Homepage/ www.gdc-uk.org www.feetforlife.orgg

LCH Approved Acronym List

SERVICE NAME Acronyms Version X

Liverpool Community Health does not advocate the use of acronyms within Health Records or Clinical Documentation but recognises that approved acronyms can speed up the record keeping process. Therefore the list of acronyms below have been approved for use within SERVICE NAME at Liverpool Community Health.

The acronyms on this list have been approved on XX/XX/XXXX and will remain valid until an updated version is published (at which time an end date will be added)

ACRONYM MEANING ACRONYM MEANING


MAX 60 acronyms per service. To fit on one page of A4 to be inserted/printed on every record. If a revised version is approved whilst the patient in undergoing treatment both versions should be put into the record and the ‘older version’ should have an end date placed upon it.No symbols or ‘shortened’ words are to be used eg ° for Degree or Abb for abbreviation are not acceptable.Acronyms should be listed alphabetically by acronym, not meaning.

Appendix 6 – LCH Services Record Format

ElectronicABACUS ECGLOOHS Social Work (shared record with Local Authority) Medicines ManagementPhlebotomyPractice Nurse Development Team Safeguarding AdultsWalk-in-CentresX- ray & Ultrasound

HybridAdult Speech & Language Therapy Bed Based Intermediate Care Cardiac TeamChildren’s Community Matrons Children’s Liaison ServiceCommunity Equipment Nurse Specialists Community Equipment Service Community MatronsCommunity Occupational Therapy Community Respiratory Team DentalDiabetes Team Discharge Planning Team District NursingFamily Nurse PartnershipHealth Promotion – Stop Smoking Health VisitingHIV Team IV Therapy LAC TeamManual Handling Palliative Care


Primary Care Practices PodiatrySAFE PlaceSefton Stop Smoking ServiceSexual Health – domiciliary, ED, psychosexual and trans support services School NursingSkin Service TB ServiceTelehealth (shared record with provider) Treatment RoomsWheelchair Service YOT

PaperArmisteadChildren’s Additional/Complex Needs Children’s Speech & Language Therapy Continence ServiceCommunity Assessment Team Community Intermediate Care Team DieteticsEmergency Response Team LiveabilityLOOHS TherapyPaediatric Dietetics (Sefton)Paediatric Occupational Therapy (Sefton) Paediatric Physiotherapy (Sefton)Rehab @ Home


Appendix B


Records Management Scanning Documents


Version Control

Version Number: 1.0

Ratified by: Records Management Sub Group

Date of Approval: (Original

Version)October 2015

Name of originator/author: Deputy Records & Child Health Manager

Approving Body / Committee:

Date issued: (Current Version)

Review date: (Current Version)

Target audience: All Staff, Contractors, students within LCH.Name of Lead Director

/ Managing Director: Medical Director

Changes / Alterations Made To Previous Version (including date of changes)Consultation Records Management Sub Group,

Technology Innovation and Governance Sub Committee

This policy should be read in conjunction with the following documents:

Records Management Strategy Retention, Storage and Destruction Policy. Protocol for the Management of the Records for Adopted Children. NHS Health Record and Communication Practice Standards for Team

Based Care 2004. Consent to Treatment Policy. Patient Identification Policy Transfer of Children’s Records Policy Information Governance Policy IG Guidance 05 - Tracking and Tracing Systems Confidentiality and Information Sharing Policy Confidentiality and Information Sharing Policy Data Protection Act 1998 Policy Data Quality Policy Information Governance Policy Information Governance Strategy Information Security Policy


Contents

Section Page1. Introduction 4

20.1 Status20.2 Purpose

20.3 Aims20.4 Scope

2. General Policy Statement 6

3. Definitions 6

4. Duties & Responsibilities 9

4.1Duties within the Organisation

5. Business Procedures and Processes for Scanning 10

6. Training Requirements 11

7. Enabling Technologies 117.1 Scanning Devices7.2 Storage Media

8. Scanning Into Information Systems 128.1 Type of Document8.2 Duplication8.3 3 Misfiling8.4 4 Preparation Prior to Scanning8.4.1 Photocopies8.5 Images8.6 6 Quality Control8.7 7 Retention8.8 Audit8.9 Security and Protection8.10 System and Data Integrity

9. Supporting Policies and Information 14

10. Relevant Legislation/Statutory Requirements/Government Documents 15

11. References 16

12. Appendixes 16


2.0 IntroductionEnsuring that documents are legally admissible is a core function of Records Management; any documents that are scanned must be a true representation of the original.

Proving authenticity of a scanned document is crucial if the document is required as evidence in court, this includes any documents scanned into IT systems currently in use with in Liverpool Community Health (LCH).

LCH has a duty to ensure documents scanned, stored and migrated through electronic systems meet the evidential weight as outlined in the Civil Evidence Act 1995 to ensure legal admissibility should a court require it.

1.5 StatusThis is an Organisational wide guidance.

It provides standards that will be adhered to by all Clinical & Corporate staff, across all professional groups who are working within LCH, who are required to manage records and scan information into any LCH adopted electronic system.

As this guidance directly supports the LCH Records Keeping and Management Policy persistent failure to comply with the requirements of this guidance may lead to disciplinary action by the Trust, and / or reporting to the appropriate registration body.

This document has been created in conjunction with BSI DISC PD0008 - 'Legal Admissibility and Evidential Weight of Information Stored and BIP 10008:2014 legal admissibility and evidential weight of electronic information.

1.6 PurposeThe purpose of this document is to provide guidance and clarity in the steps that must be taken to scan and quality assure the electronic document.

This guidance will establish guidelines for the legal admissibility, authenticity and integrity of scanned, stored and electronically communicated information.

It is designed to ensure we meet our legal obligations in relation to Records Management and to work within the wider framework of Information Governance (IG). The guidance will set out expected standards, and reference appropriate guidance, where applicable, for staff to follow in relation to the management of all records, clinical and corporate. Where appropriate, staff will then develop service/system/departmental procedures and guidance to ensure that records can:

Improve reliability of , and confidence in scanned documentation into LCH electronic systems

Provide guidance on process, procedure and audit to ensure authenticity, quality and legal admissibility of scanned information.

In turn this will:


Provide accurate and comprehensive information that is available for the delivery of safe, high quality care

Enable information for teaching, research, and audit and as evidence in the event of a complaint or litigation

Comply with local standards for health record keeping will facilitate the assessment, care, treatment and support of a service user.

Generate appropriate records of professional intervention and outcomes that are a requirement of, and an indicator to, the standard of professional practice.

Readily accessible and available for use when needed to give a better use of staff time

1.7 Aims

The aims are to:

Provide guidance on process, procedure, audit in order to ensure authenticity, integrity, security and legal admissibility of scanned, stored or migrated information.

Improve reliability of, and confidence in, communicated information, and electronic documents to which an electronic identity is applied.

Maximise the evidential weight which a court or other body may assign to presented information Provide confidence in inter-organisation information sharing

Scanned documents are available when needed so that events or activities can be followed through and reconstructed as necessary

Scanned documents are accessible, located and displayed in a way consistent with their initial use

Scanned documents are trustworthy and hold integrity, reliably recording the information that was used in, or created by, the business process;

That all scanned documents are maintained over time, irrespective of any changes of format so that they are available, accessible, able to be interpreted and trustworthy;

That all scanned documents are secure from unauthorised or inadvertent alteration or erasure, with access and disclosure being properly controlled and audit trails tracking use and changes;

Documents are shared, where appropriate, with other professionals in line with the Information Security Policy and Information Governance Policy, taking into account patients consent

Scanned documents are held in a robust format which remains readable for as long as records are required;

Scanned documents are retained and disposed of appropriately using documented retention and disposal procedures, which include provision for reviewing and permanently preserving records with particular archival value.


1.8 ScopeThis applies to all persons who are employed by, or act on behalf of LCH including both professional registered staff and non-registered staff, for example Health Care Assistants, Therapy Assistants and Students

2.0Definitions

Audit Trail

Corporate Records

Contemporaneous

Data which allows the reconstruction of a previous activity, in its correct chronological place, or which enables the attributes of a change (such as date/time, operator) to be recorded

Records (other than health records) that are of, or relating to, an organisation’s business activities covering all the functions, processes, activities and transactions of the organisation and of its employees. A document becomes a record when it has been finalised and become part of the organisation’s corporate information. At this point, the record must not be amended and should only be held in the corporate system, for example, the network drive or shared folder and not on a local drive on a personal computer or laptop.

As soon as possible after contact with the service user and within the same working day (Department of Health 1990).

DataSeries of digital or analogue signals or encoded characters stored or transmitted electronically, or marks (e.g. writing, printed characters, graphics) on paper or microform, which are intended to convey information

Decompression Process of reconstituting a file which has been compressed back to its original form, or to a close approximation thereof


Deletion

Destruction

Process of logically removing a document from a system, often by deleting an index reference

The process of eliminating or deleting records beyond any possible reconstruction.

Digital Image Image consisting of pixels using ranges of discrete values

Digital Signature

Disposal

Data appended to a data file that allow the recipient of the data file to authenticate the source and the integrity of the data file

The implementation of appraisal and review decisions for the destruction, permanent preservation of records or the movement of records from one system toanother (for example, paper to electronic)3. This will be treated as appraisal within this document and is considered at all stages of the Records Management Lifecycle

Document Information stored on media

DPI

EHR

Dots Per Inch, a measure of resolution

Electronic Health Record

Electronic Signatures Computer data compilation of any symbols executed, adopted or authorized by an individual to be the legally binding equivalent of the individuals handwritten signature

Electronic Storage Storage medium or device used by an information management system to store information

Encryption Reversible process of converting a data file into a secret code under the control of a key

Expungement Process of removing a document from a system and leaving no evidence of the document ever having appeared on the


Health Recordsystem

A single record with a unique identifier containing information relating to the physical or mental health of a given patient who can be identified from that information and which has been recorded by, or on behalf of, a health professional, in connection with the care of that patient.This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the on-going care of the patient to whom it refers (Department of Health 2006).

Information Management System Any computer or other electronic system which stores and/or processes information in digital or analogue form

Original Document Document from which a copy is made or from which an image is captured

Page Single image entity, such as one side of a sheet of paper, a drawing or plan, map, photograph, transparency; or a microform ‘frame’

Pixel

Protective Marking

Smallest two-dimensional element of a digital image that can independently be assigned attributes such as colour and intensity

Records should be marked to signify the nature of the contents and the level of security that should be applied to them. NHS Confidential This is appropriate for documents and files containing person- identifiable or sensitive clinical or staff information.NHS Private This applies to information that would need to be handled with care, and would be restricted from release to the general public or staff (if only for a limited period of time).NHS Public These records are considered to be routinely made available to the public and staff.


Record Information created, received and maintained as evidence and information by an organisation or person, in pursuance of legal obligations or in the transaction of business (BS ISO 15489:2001)

Records Management Field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records, including processes for capturing and maintaining evidence of and information about business activities and transactions in the form of records (BS ISO 15489:2001)

Resolution Ability of a scanner or image generation device to reproduce the details of an image

Scanning Operation that converts the image of a document into a digital form, by detecting the amount of light reflected from elements of a document

System

WORM media

In the Policy, this always means information management system unless specifically noted

Write Once Read Many media conversion preventing modification to scanned documents

4.1 Duties and Responsibilities

This section of the document provides an overview of the individual, document development. This includes the levels of responsibility for the policy.

4.2 Duties within the Organisation

4.2.1 Chief ExecutiveThe Chief Executive is ultimately responsible for the content of all policies and their implementation.

4.2.2 SIROEnsure that the Compliance and admissibility issues are incorporated in systems and outputs and are reflected in the Assurance Framework. Board lead for information


risks thus ensuring risks associated with information systems are monitored and addressed.

4.2.3 icott Guardian

Ensure that Caldicott Guardian principles are embedded and monitored in the Trust.

4.2.4 verpool Community Health Board - The board is responsible for setting the strategic context in which organisational policies and procedures are developed, and for the formal review and approval of LCH policies.

4.2.5 ds of Department responsibilityHeads of department are responsible for management of records within their department(s). This includes:



4.2.6 ds ManagerDelegated responsibility to ensure that policies, procedures and guidance is in place, in line with legal requirements and best practice, to comply with IG related work areas including the management of all records. This includes:





5. Business Procedures and Processes for Scanning

Each service implementing a scanning process for the storage of documents should also develop a flow chart detailing the process for ease of reference.The procedure and processes must be audited annually to make sure that the approved procedures are being observed.


The Policy may be used as a common reference standard for business activities within the Trust and between organisations and for subcontracting or procurement of information technology services or products.

The requirement to authenticate scanned documentation can be covered with evidence to key questions:

When the electronic information was captured, was the process secure? Was the correct information captured complete and accurate? During storage, was the information changed in any way, either accidentally

or maliciously? What was the process for scanning paper originals into the system? Can the trust evidence the quality and integrity of the original document

has been maintained?

Completion of standard operating procedures (SOP) for scanning documents onto electronic systems should be do in conjunction with this policy and have full involvement with the Records Team before implementing.

6. TrainingTraining needs of staff will vary according to the local scanning processes and procedures constructed to underpin this policy by local service needs.

7. Enabling TechnologiesA typical system will be comprised of many different technologies. Each of these technologies or their component parts will need to comply with BIP0008. Such technologies are:

Storage media Access control mechanisms System and data integrity Image processing Compression techniques Compound documents Data migration Document deletion

7.1 Scanning DevicesAny device that is selected to scan information must comply with BIP10008, to ensure you are using the correct device please contact the Records Department before you scan documents and attach to Information Systems.

Desktop Scanners – small scanning devices that are directly linked to a desktop computer, can process limited volumes of paper and therefore not appropriate for services with large volumes of documents that require scanning.

Multifunctional Devices (MFD) – usually large photocopiers with a scanning functionality set up. Can scan large volumes however before undertaking this option you must consult with Informatics Merseyside and The Records Team on how the and where the document will be scanned to.


7.2 Storage media

There are two types of storage media, distinguished by the medium’s ability to be written to many times or just once;

Write Many Write Once (WORM)

Data stored on magnetic disk can in principle be modified. However the risk of this happening, while significant, is small and the risk can be minimised if not eliminated altogether by ensuring that adequate controls are implemented in both the storage system and the information access control system.

Users with read only access are unable to modify data but those with read/write can. Therefore it is essential to securely log at system level the users with read/write access so that unauthorised writes to the system can be detected.

8. Scanning into Information Systems

The purpose of the process is to ensure: Authenticity and Integrity of stored data Legal admissibility of scanned, stored and electronically communicated data Improve reliability and confidence in communicated information and

electronic documents. Provide confidence in inter-organisation information sharing

8.1 Type of Document

Identify documents for scanning, carbon copies or ultra-shiny paper increases the risk of information being lost due to the quality of the original document. Shiny paper can be photocopied first to reduce the glare; this then becomes the master document and must not be modified. Carbon copies, the individual must attempted to scan the original document, if this is not possible please consult the Records Team for guidance on how to prepare the document.

8.2 Duplication

If duplications are found these should be destroyed and not form part of the scanned document. It is imperative however that if a duplicate has any handwritten information that has been added after the date of the original document that this is retained and scanned.

8.3 MisfilingCheck that all the information in the document pertains to the same patient (NHS No: Name and DoB). If misfiled information is found it must be removed and relocated to the appropriate record.

8.4 Preparation Prior to Scanning


Documents should be examined prior to scanning to ensure their suitability. Such factors as their physical state (thin paper, creased, stapled, etc), if the original copy is of such a poor state it is advised that the record be either retained in its paper format or transcribed onto a new paper document before scanning

8.4.1 PhotocopiesIt is essential that any part of the document that is photocopied whilst following the above process looks exactly like the original, nothing more and nothing less.

If the original document is of such poor quality that it is unreadable and photocopying and/or enhancing does not improve the readability of the original, then a note should be placed on file stating ‘Parts of this document were unable to be scanned due to the poor quality of the original’.

8.5 ImagesImage processing is a post scanning technique to improve the quality of a scanned document. There may be good reasons for improving image quality but it is NOT permitted for clinical photography in case essential detail is removed.

8.6 Quality ControlIt is important to be able to demonstrate to a court that the quality controls are adequate and work. A peer audit will take place on random scanned items by the Records Team to ensure quality assurance is maintained.

Following scanning – a check should be made of the paper document against the scanned document, ensuring that:-

The same amount of pages has been scanned and all pages are legible and exact replicas of what you hold.

Once a document is scanned it should not be reprinted for clinical purposes, with the exception of outside agencies or the patient requesting the record.

8.7 RetentionNo original documentation should be destroyed until quality checks have taken place and assurance the scanned documents are legible and stored securely. All original documentation to be kept for one month to ensure adequate time has been allowed before shredding under confidential conditions.

8.8 AuditThe procedure and processes will be audited annually to ensure that procedures are being observed. The audit trail as a minimum will log details of each significant event in the life of the document within the Information System. The audit trail will be generated by the system of the user, date and time and stored securely within a user’s access role.This audit will be held centrally by the Records Team.

8.9 Security and ProtectionSecurity and protection covers user access which will capture details about the User, Date and time of scanning took place. Users with read only access is unable to modify


data but those with read/write can. Therefore it is essential to securely log at system level the users with read/write access so that unauthorised writes to the system can be detected.

8.10 System and Data IntegrityThis will be covered by Data Quality Policy and a robust Audit Trail.

9. Supporting Documents

NHS Health Record and Communication Practice Standards for Team Based Care 2004

Records Management: NHS Code of Practice. Department of Health Freedom of Information Act 2000 London: Stationery Office (FoIA 2000) Human Rights Act 1998, London: Stationery Office. Data Protection Act 1998 London: Stationery Office. (DPA 98) The Public Records Act 1958 London: Stationery Office. The Public Records Act 1958 (Admissibility of Electronic Copies of

Public Records) Order 2001 The Public Records Act 1967 London: Stationery Office. Access to Health Records Act 1990 London: Stationery Office. Setting the Record Straight 1995 Environmental Information Regulations 2004 NHS Information Governance Guidance on Legal and Professional Obligations Information Governance Toolkit Care Quality Commission Standards NHS Litigation Authority Standards The National Archives, Records Management Standard BSI DISC PD0008 - 'Legal Admissibility and Evidential Weight of Information

Stored BIP 10008:2004 legal admissibility and evidential weight of information

stored electronically ISO 15489 – 1:2001 Information and documentation – Records Management ISO 27001 International standard for Information Security Caldicott Review of Patient Identifiable Information (1 & 2) http://www.aomrc.org.uk/ Standards for the clinical structure and content of

patient records


Appendix 2 Simple Scanning Steps

Scanning – What to do first?

Identify documents eligible for scanning

Prepare documents for scanning

Ensure that the device you are using to scan is approved and in working order

How to prepare for scanning:

Check for ultra-shiny fax paper - this will not scan properly and needs to be photocopied before being scanned to ensure legibility.

Check for carbon copies – are they faded to much to scan

Remove any staples or paperclips.

If forms are folded these will need to be divided into separate pages and kept in order, however you should ensure that writing in the forms does not cross the central divide.

It is essential that any part of the document that is photocopied whilst following the above process looks exactly like the original, nothing more and nothing less.

When to destroy originals

Nothing from the document should be destroyed until scanning and quality checks have taken place and the retention period has been met.

All original documentation to be kept for one month to ensure adequate time has been allowed before shredding under confidential conditions.

For example: All documents scanned in January need to be retained until end of February before destruction can take place.

The one month retention period has been implemented by The Records Team and approved to ensure we meet quality checks and to

alleviate storage problems within the services.


eric am mail ount

Email

Save the document from

email to network drive

Per

son

B (C

linic

ian)

Per

son

A (A

dmin

)

Is Original Fit- for-Purpose?

No

Yes

NoEnsure that ‘Delete Original’is selected when scanning

the document

Is QualityAcceptable?Yes

Documentmust be stored in

lockable area identified and approved by LCH Records Management

NFEmail orNetwork FolderGen

Te E

Acc

Contact Referrerand request new

copy

Please refer to LCH RecordsManagement Guidance – available on LCH Intranet

Primarily an admin task but ifno admin available then this

should be picked up by a clinical member of staff

MFDNo

Slave ScannerSlave or MFDYesIs Quality Acceptable?

Inbound Referral Via Fax

Referral Information added on to EMIS Web

Authors: Ryan Lomax, Project Manager, Informatics Merseyside & Sam Curtis, DRCH Manager, Liverpool Community Health

LCH Scanning – EPR Non-SPC Pilot

Delete scanned image from

network drive

Find Original Document

Re-Scan Document and follow earlier

process

Open Network Drive to view

document

Find Patient on EMIS

Edit the appropriate consultation

Attach the document to the

consultationSave Consultation

Delete Email once document is saved

Empty Deleted Items when complete

Store Paper Copy of the Document

Document saved to network folder

Scan DocumentCheck Quality of Paper Referral

Fax picked up by Admin or Clinical

Staff

Hand back to Person A to

contact Referrer

If scanned multiple times and quality

is still not acceptable refer to

your local IT Service Desk

Confidentially destroy paper

document


Scanning into EMIS1. Enter the Scanning & Documents Module by clicking on the Scanning and Documents icon on

the Quick Access Toolbar or by clicking on Scanning and Documents on the Quick Launch Menu or by going into the EMIS Ball and into system tools

2. Load the patient documents into the scanner face down and click on the Scan icon

3. Each page of the document, front and back will appear in the Source Files list. Select the correct file you would like to preview

4.5.The

document will nowappear in thePreview section. You will need to assess the quality of the scanned


document compared to the paper copy. You can Rotate the document by using the rotate buttonsIf the scanned document is not acceptable you can Delete the document by clicking on the

delete icon and you will have to rescan the document

6. If the scanned documents are acceptable (according to the LCH scanning policy) you will then need to add each page to Add Selection by clicking on the icon

7. Once all the pages are moved to add selection click on the Save in New Record icon


8. You will need to search for the correct patient

9. You will then be shown the document before filing it in the patient record

Link to Referral – This allows you to link the document to a referralAdd Task – This allows you to send a task

Type – Add the type of document by using the magnifying glass. Once you have used an option it will appear in the dropdown list.

Document to be scanned Document Type Read Code

Printed laboratory result Laboratory result 9b0Q

Referral Referral letter 9b0g

Any other letter received about a patient that is not a referral

Letter received 9N3D

Source – Add the source of the document by using the magnifying glass. Once you have used an option it will appear in the dropdown list

10. Click File at the bottom of the screen to file the document into the patient’s record


Quality Checking of Scanned Records: What is to be passed and what is to be failed.

This guidance has been created as an aid during the quality checking of scanned images. When a record has been identified as not suitable due the information not being legible please consult with you line manager.

A scanned image should always be of the same quality as the original, this is the main focus whilst quality checking. Once a scanned record has been checked and passed its original copy will be destroyed, the upmost attention to detail must be used during this process.

Please note images used for the purpose of this guidance document have been extracted from CG Gold and therefore are only a guide to how a scanned image is presented.


This is an example of a record that was cropped/cut before it went for scanning and not what occurred during the scanning process.


This is how a health record should look like once it has been scanned onto the CG Gold Database. As you can see all of the patient’s information can be clearly read and used by a clinician if recalled.


This is an example of a document that was originally faxed and then has gone through the scanning process. As you can see it has faded in some areas however all the key information is still available. To determine whether or not it was a fax look at the top or bottom of the page there should be a fax by date and time written on in small print.


This is example on a scanned document which will need to be tagged and then failed. As you can see the majority of the document is illegible and could not be used if requested back.


This is an example of a document that has moved during the scanning process. Due to the angle at which is set there could be key information lost in the bottom right hand corner. This image is to be failed and tagged for re-scanning.


This is an example of two records that have been merged through the scanning process. A small sheet of paper is now obscuring the larger records and covering certain information. This image is to be failed and tagged for re-scanning.


This record will pass the quality check as all the relevant information can be viewed. However it is an example of what a record would look like if it is folded during scanning. The top left corner is black were the scanner has nothing to scan. If this fold was larger and covered the information it would be failed and tagged for re-scanning.


Appendix C

Records Management – Tracking, Tracing and Transfer of Records


Version 3Date August 2015Status DraftAuthor Deputy Records and Child Health ManagerApproved By Records Management Sub Group (RMSG) , Information

Governance Sub Group (IGSG)Consulted Information Governance and Records Team, Records

Management Sub GroupChanges Version 2 – Updated to include further guidance on process for

removal of records page 3Version 3 – Change to author titleChange to include transfer of paper records internal and external


IntroductionAccurate recording of all record movements is essential if information is to be located quickly and efficiently. A well maintained tracking system will not only improve the availability of information at the right time but also improves the quality of services by saving the time of health professionals and the service users.

The Records Management Policy mandates that there must be tracking and tracing systems in place for monitoring the physical movement of records. These take different forms, and this guidance is designed to explain a number of them so that you might implement the best one for your service.

Transferring of patient records off site whether it is for the purpose of patient interaction or due to team movement / caseload movement must tracked through your tracking and tracing system.

Purpose To improve the tracking of case notes To enable retrieval of case notes when needed To monitor usage for the maintenance of systems and security To maintain an auditable trail of record transactions To ensure the safe movement of records from

Before implementing a tracking and tracing system

Determining which system should be used is a decision which needs to be based upon the requirements of the operational area(s) concerned, the number of file movements, the level of usage of the records, the demand for performance management information and the organisation’s requirements to maintain accountable records of particular activities.

The system adopted should maintain control on the issue of records, the transfer of records between persons or operational areas, and return of records to their home location for storage.

To support with the appropriate decision please consult the Records Team.

Control Systems

All control systems for monitoring the movement of records depends for its success on both the accuracy of the filing system and the means of recording the location of records that are out of file, this is the responsibility of all staff.

Systems for monitoring the movement of records include:

Patient Administration System (PAS)Preferred choice to manage tracking and tracing of active patient records in and out of the filing area, it ensures that appropriate audits are in place and links all activity concerning the patient in one area.


SpreadsheetsA computer programme which allows for the manipulation of information affording the user to view multiple entries simultaneously. This system is useful for tracking the movement of large amounts of records and can be password protected to prevent any unauthorised access.

Computer databasesA more structured format for monitoring the movement of individual patient information. Record Tracking Databases retain the history of movement and the staff that have accessed that patient information allowing for an easy to access audit trail. Detailed patient identifiable information held on any database must be identical to what is held in the physical copy, deviation from this can lead to misfiles and loss of information. An electronic system reduces time spent physically checking through filing areas and should contain reference to where the record is held.

Bar codingBarcode labels on the front of the record containing the patient’s unique identifier can also be used to track the record using a barcode reader/scanner which will automatically scan the label and insert the patient information on the tracking screen. This helps to ensure that there is less chance of wrong keying of a number or letter. This system is again particularly useful to large services that have frequent movement of large volumes of records and can be managed through a PAS

Paper basedThis system commonly comes in the format of Tracer Cards and is usually cut to the same size as the record folders and these replace the record in the filing system when it is removed. The tracer card will give key patient identifiable information, the date and person that removed it and its current location. Another variation of the tracer card is the issue of a library card for each set of notes. This card is kept in a pocket of the record. It is removed and the details of the borrower filled in and it is then filed in a separate card index drawer. Checks to determine the location of records have to be made and all incoming records have to be checked and the cards returned to the record. The paper system is heavily dependant on a well designed filing system and can be time consuming.

Combination systems – Electronic & PaperThe utilising of two systems to work as one provides sufficient ‘back up’ when transferring and tracking a record, an example of this would be the tracer card system and computer record tracking database.


Process for the removal of records for patient contact

It is the policy of the Liverpool Community Health Trust that the movement and location of records will be controlled to ensure that records can be retrieved at any time, that any outstanding issues can be dealt with, and that there is an auditable trail of record transactions. This includes records selected for off site storage, migration to other media and destruction.

If records need to be transported from a clinical filing area for the purpose of a patient visit it is the responsibility of the staff member to ensure that at no point could the records be accessed by an unauthorised individual. It is the staff members’ responsibility to ensure the safety and security of records whilst in transit.

The below steps provides guidance on how to minimise the risk of any loss and what to do in the event of any subsequent loss:

Where a record tracking and transfer system has been implemented all newly created health records must be tracked using the correct function. This will ensure that whenever a record moves location thereafter it can be tracked on the system.

All health records removed/borrowed from their store must be immediately tracked out on the electronic tracking system, where appropriate, or replaced in the file with an accurately completed manual tracer card. For records selected for destruction the additional relevant procedures must be followed and the log completed

As a minimum the tracer/tracking systems should record.i. The record identifier (Patient Identifiable Information)ii. A description of the item (Health Visitor Record)iii. The person who removed the record from storage.iv. The date / time removedv. They are being held and when they will be returned.

There must be careful consideration of how they will be stored whilst off the premises and arrangements should be made to return the records as soon as possible.

During transit the records must be stored securely such as in the locked boot of a vehicle. Records should never be left in an unattended vehicle, even if the vehicle is locked.

If it is absolutely necessary to retain the records overnight these should be kept in the same conditions of security as on Trust premises i.e. in a locked cupboard within a locked building. Not left in a vehicle overnight. All records must be kept confidential from non-Trust employees whilst off the premises.

Whenever a health record is removed from its storage area it is the responsibility of the borrower to record the new location quickly and accurately on the tracing/tracking system in operation. This will ensure that health records can be located quickly and efficiently when they are required for patient/client/service user


care. Where tracking


is done via the computer, health records should be tracked in “real time” wherever possible.

Borrowers of health records are personally responsible for the security and subsequent return to store of every set of health records that they borrow.

Borrowers who take or send health records to another location are personally responsible for ensuring that the computerised tracking system or manual tracer card system is updated immediately. The last recorded borrower is personally responsible for any health record that is missing.

The loss of patient’s records or divulging of information to unauthorised individuals is a serious matter. If this occurs, consideration will be given to invoking disciplinary proceedings, dependent upon the circumstances of the loss/disclosure.

Internal Transfers of Records

To mitigate any loss of patient information during internal movements of records (site to site) Liverpool Community Health (LCH) has two approved companies to physically move patient information.

Health Record Archive – Box-it

Active Record Movement – Fast Transport Services (FTS)

Records identified for internal movement should not be transported by staff as this increases the risk of potential loss of records.

The HSCIC has recently revised its guidance on when an NHS Trust must inform the Information Commissioners Office (ICO) of any data loss, this includes paper health records, and subsequently this has now informed the following guidance on the volume of records and the method of their transportation.

Nine or less Health Records

Internal Post – Ensure you follow the Safe Haven Policy

Post principles

NHS Confidential or NHS Protect relating data/information sent by post should ensure: It is addressed with full name, department and full address (including postcode) of the recipient

It is sealed securely in a robust envelope, if necessary for bulk items double wrap or tape envelopes to ensure the seal is robust

It is marked “Private and Confidential”

Confirmation of receipt is requested


A return address is included (on rear)

Post is not used for urgent transfers of data

External Post

Refer to LCH Safe Haven Policy located on the LCH Intranet Site

Plus Nine Records

Any number of records in excess of 10 should be placed into a box and catalogued (listed) and arranged with FTS for collection and delivery.

Caseload movement should firstly be consulted with the Records and Estates team to ensure that appropriate storage is available to house the moved records. Again all records moving need to be catalogued electronically (spread sheet) and a copy should be retained by the service. On moving the records a clear date for collection needs to be communicated with key individuals at both sites identified for signing out and taking receipt of the records.

Any team movements should refer to The Moving Guidance

If in case of an accident in a car and records are in the boot ever effort should be to recover the records and return to LCH.

Record Archive

Please refer to the Archiving Guidance located on the LCH Intranet site

Record Loss

If, despite the tracking and tracing process being in place within your team or service, a record is lost all efforts must be made to locate the record before a new record is created. If the original record is subsequently located the record needs to merge with the temporary new record in a correct chronological order.

When creating a temporary record the following must be recorded:

• Date temporary record created• Name of person creating temporary

record If the record is found:

• Temporary record & original record merged (name of person merging records and date merged)


Before reporting a lost record on Datix the following steps must be followed:

Record cannot be located within the team/service by Administration staff or the Clinicians.

Team/service to check if the missing notes may have been transferred out or sent for archiving/scanning.

If this has not been the case an immediate search of the filing system, desks and drawers should be carried out involving as many team members as possible.

Records team staff to visit the site of the missing records and carry out a fingertip search and re check desks, drawers etc.

The records team will check all systems and databases to ensure the record is not held at the Central Records Store.

Team Leader to contact Records Management and inform them that notes are missing

If the record is still not located the team will need to inform their Team Leader.

If record is still not located the Team Leader of the team/service where the record has gone missing from will need to complete a Datix and inform the patient that their information has been lost


ProceduresIt is important that all members of staff who handle health records are aware of the importance of correctly tracing/tracking health records in order to maintain continuity of care, security and confidentiality. Written transfer and tracking procedures should be in place for staff to refer to if unsure and new starters to the team given the procedure on their induction.

For support on the creation of tracking and tracing procedures please consult the Records Management Team

Audit & MonitoringRecord tracking is the process of recording the movement of a record to produce an audit trail (a list of the record's movements).

The tracking of records usage within a records management system is necessary to:

Ensure that only those users with appropriate clearance or permission are performing tasks for which they have been authorised.

Ensure that the record has arrived at its intended destination; a time frame should be agreed between the sender and recipient as to when the record should have arrived by, failure to arrive within the time limit should prompt the sender to initialise a search for the record.

It is recommend that a regular audit of the transfer and tracking systems is performed by the team/service, this is to identify any training requirements or share best practices.

ReferencesThis guidance is to be used in conjunction with the following policies and guidance

Records Management Policy (Clinical & Corporate) Safe Haven (Secure) Transfers of Information Information Governance Incident Reporting Awareness Moving Guidance Archive Guidance HSCIC – Checklist for Reporting, Managing and Investigating

Information Governance Serious Incidents

Useful Contacts

Records Team – 0151 295 3263

Records Team Email – [email protected]


Appendix D


Archival of Records Procedure

Version Date Issued Changes Owner2.0 September 2014 Process re-written

to support change in provider

Records Management Team

Version Number 2.0Approving Body RMSGDate of ApprovalRatified ByIssue DateReview Date September 2015Target Audience Organisation WideLead Director

Contents PageBackground 2Purpose 2Contacts 2Archiving Options 2Process Overview 3Appendix One – Template list 4Appendix Two – Barcodes and NBDS 5

Appendix Three – Collection of archiving for Deep Store and Scanning

6

Appendix Four – Internal Records Request Form

7


Appendix Five – Deep store and Scanned requests

8

Appendix Six – Returning requested records 9

1 Identifying records for archiving

NHS Code of Practice for Records stipulates that storage accommodation should be clean and tidy, should prevent damage to the records and should provide a safe working environment for staff. The storage of closed records should follow accepted standards relating to environment, security and physical organisation of the files. Secure and environmentally safe storage is vital to ensure that records are maintained in good order and available as and when required therefore we do not advocate the use of cardboard boxes in store rooms as a place for holding ‘discharged’ records. Archiving via the Records Team should take place when the filing area is at full capacity to avoid the risk of records being stored inappropriately.

2 Purpose of Process

To outline a generic and consistent approach to the archival of records within LCH This standardised procedure will be managed by the Records Management Team.

3 Contacts – Records Management Team

Designation TelephoneRecords Co-ordinator 295 3264Records Co-ordinator 295 3265Records Team Supervisor 295 3263Senior Records Clerk 295 [email protected] 295 3263

4 Archiving Options

The three options for the archiving of records are:* storage at the central records store (70 Everton Road)* deep store at our secondary storage site (Box It)* digital scanning onto OMNIDOX

The records team will decide how your records are to be archived based on the volume of records, size of records and recall rate.

Services that currently scan ‘active’ records this will continue and we will work with you to support the transition between software.

Any records that have exceeded their retention date should be securely disposed of using the relevant guidance documents. Records retention periods can be found in the records policies section of the intranet


http://nww.liverpoolch.nhs.uk/Downloads/SERVICES/CORPORATE/IMT/Records/IG_Guida nce_04_-_Records_Retention_Periods.pdf


3 Process Overview


Appendix One - Template List

Please ensure that any archiving is listed on the required template for electronic PPI. See below. In order to meet the requirements of Box It, any PPI’s that are not completed in the correct format will be returned to the service and collection of your archiving will be significantly delayed.

For example, PPI for Community Matron records to be archived.

Please rename the page to mirror the box number you are listing. See the bottom of the PPI below shows that this page is the patients contained in box 4.


Appendix Two - Barcodes and New Box Deposit Schedule

Box It identifies each box of patient records by using a unique barcode number. Once you have informed the records team that you have archiving to be taken off site we will identify if and what barcodes are needed for your archiving.

Records that are to be held or processed at Everton Road do not require a barcode sticker.

Records that are going to deep store will require a white barcode sticker. Records that are going to be scanned on to Omindox require an orange barcode

sticker.Barcodes will be sent to you via the internal post along with a New Box Deposit Schedule (NBDS). The records team will complete the first part of the NBDS and assign your archiving with a unique reference code. The barcode sticker is placed in the space provided on the boxes, with a second smaller sticker placed on the place provided on the NBDS.

The image below is for records that have been sent to deep store:

White barcode sticker – F000401285 Unique reference code – 472 -33. This means consignment 472 box number 33 Review date – 0420. This means April 2020 the records will be reviewed to

be destroyed so they will be April 2012 discharges.


Appendix Three – Collection of Archiving for Deep Store and Scanning

Once the barcoding and NBDS form are complete you must notify the records team so that you collection can be arranged. Once Box It have been contacted the records will be collected from your site within two working days.

It is important that all of the information is correct on the NBDS form and all archiving has been included, Box It will not accept any boxes that have not been included on the collection request from the records team.

If the boxes that contain your archiving are not fit for purpose, eg snapped handles, no lids, the bottoms caving through etc, they can refuse to take these. It is important that if you do not have suitable archiving boxes at your site that you request these from the records team before you begin archiving.

The Box It driver and you must both sign and date the NBDS form. You then need to take a photocopy and always give the Box It driver the original form. Keep the photocopy for your team along with the pickup receipt that the driver will give you. These will need to be


scanned and saved electronically into a folder for your team to refer to in the future. If you ever need to request a record back it is imperative that you have kept all of this information.

Appendix Four - Internal Records Request Form

If it has been decided that your service’s archiving will be held or processed at Everton Road and you require a record back you must follow the instructions below.

Contact the records team for a record request form. See image below Fully complete the form to avoid it being returned for more information Send electronically to [email protected] The record will be sent via internal mail the following working day Please inform the records team via email when you receive the record


Appendix Five – Deep Store Records and Scanned Image Requests Form

If your service’s archiving has been sent for Deep Store with Box It, or to be scanned on to Omnidox and you require a record to be returned you must follow the instructions below.

Request the relevant form from the records team Refer back to your archival information to ensure you have all of the correct details

to complete the form fully. Return the completed form, see below, to the records team inbox.


Returning Requested Records

In order to prevent any loss or misplace of records it is important that we keep an audit trail.

If a record is requested to be returned from deep store or the records store, you must notify the records team via email when you no longer require this record to be at your site. The records team will then arrange for the record to be returned to either deep store or the records store, were ever it was originally archived to.


Appendix E

Guidance for the relocation of services within Liverpool Community Health NHS Trust

IntroductionIt is acknowledged that services/departments may move location which could include the transfer of NHS Confidential or NHS Private Information.

This guidance is designed to support you when moving locations.

It is the legal responsibility of an organisation to ensure that the transfer of personal information is secure at all stages. The loss of personal information will result in adverse incident reports which will not only affect the reputation of the organisation but, in case of disclosing personal information intentionally or recklessly, is also a criminal offence.

This guidance document is in place to ensure compliance with the following policies:

Information Security Policy Information Governance Policy

Once informed of intention to move discuss accommodation requirements with Estates. Review current processes and procedures to ensure most efficient methods of working are in place. This can often reduce space required. Review current office space and what each area is used for. Discuss options for streamlining i.e. reducing amount of storage required or desk space needed. If moving Records, either corporate or health contact Central Records Store for specific advice and guidance.

Pre Move

1. Visit new accommodation with Estates team and roughly map out layout. Identify office/desk areas and areas for storage.

2. Arrange meeting with Estates, Records and IT to discuss and plan the move in detail and clearly identify responsibilities.

3. Gain Records team approval for the move regarding their being adequate storage space for records.

4. Records team to advise on culling existing records, correct labelling and if required, temporary storage.

5. Meet with Estates and the appointed moving company to identify and clearly label what equipment/furniture is not to be moved and is to be destroyed or put into storage. If applicable label desks, chairs etc. with staff members name.

6. Estates to arrange for crates to be delivered for equipment/records to be packed into.

7. All parties involved to agree date of the move.


8. List all records as they are boxed and place a list of contents into each crate (see Appendix A). Utilising Patient Administration Systems such as EMIS web to generate caseload lists will help with this process. Label crate with exactly what it contains and number i.e. Box 1 DN NOTES A – E (see Appendix B). An inventory should be created for all crates for checking on arrival at new accommodation (see Appendix C). Label all boxes that contain electrical equipment with exactly what each box contains and if applicable who it belongs to.

9. Ensure all lids on boxes/crates are secure and are not liable to come off or open during the moving process.

Moving Day

10.Arrange to meet Estates and moving company on site at pre-arranged time.11. IT should also be on site to set up PC’s and telephones as they arrive to ensure the

service is back up and running as soon as possible.12. If tambour units/filing cabinets are to be moved to accommodate records they

should be moved first into the new accommodation.13.Members of staff to tick crates off inventory list as they are loaded on to transport.14.Staff members to tick crates off inventory list on receipt at the new accommodation

and direct delivery people to where each crate of records /equipment or furniture is to be located.

15.Records should be re filed immediately to ensure the team/teams are up and running as soon as possible and to avoid data loss or Health and Safety issues arising.

16. If there are any items missing this should become apparent on the day if crates have been listed and numbered correctly. The new location and vehicles used in the move should be checked immediately and if the missing items are not found the location moved from must be checked.

If items are still missing review all procedures and raise a Datix. If items missing are records then contact the Central Records store for advice and if appropriate they will assist in the investigation process.

Post Move

A senior member of the Records team, an Estates representative and a Team Leader will do a final walk around of the office/building that has been vacated to ensure no documentation has been left behind during the moving process before Estates arrange for the location to be cleared of anything left behind that wasn’t required as part of the move.

Additional checklist (if applicable)


Postal services both internal/external will need redirecting. Specimen collections should be communicated and redirected. Arrange clinical waste collections. Arrange for confidential waste to be collected prior to or on the day of the move

and arrange for future collections at new accommodation. Arrange for communications both internally/externally to be sent out to make

everyone aware of team relocation including any new telephone numbers to be used.

Building managers to ensure all passes/fobs are collected for site being vacated.

Appendix – Box lists


List of Names in box

Name Date of Birth Out In


Appendix

Children’s Services Records Box 1

School Health St Benedict’s


Appendix

Crate No.

Crate Contents Description:

Checked Out

(Signature)

Checked In at New Location

(Signature)

1. Children’s Service Records

School Health

St Benedicts

2. PC and Base

PC Number xxxxxx

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.


Appendix F

Guidance on Health Records Filing within Liverpool Community Health

Health Records Guidance

Version 1.1

Date 11/04/2013

Status Approved

Author Records Child Health & Admin Manager

Approved By Records Management Sub Group

Consulted Records Team and local area records experts


Changes Appendix added to document exceptions to standardised filing


IntroductionLiverpool Community Health NHS Trust (LCH) has a wide variety of health records in circulation to support the care of their patients.

These records have traditionally been filed in accordance with local practice and accommodation provision which differs from service to service and team to team.

Regulations around the safe management of Health Records mandate that all health records held by an organisation are stored to a centrally agreed policy, and are all filed in the same way, ideally within the same location (library).

As LCH does not have a central records library for active health records it has been agreed that local ‘libraries’ can remain as long as they conform to the same filing principles.

It has also been agreed that as teams/services/buildings move then the approved filing methodology will be put into place. Any teams and services can voluntarily move to the new way of filing ahead of any planned move.

ResponsibilityThe organisation, as a public authority, has a responsibility to ensure compliance with the NHS Code of Professional Conduct: Records Management, CQC, and NHSLA in its management of Health Records.

The Records Management team are responsible for:-

Advising on how the filing system will work

Supporting teams and services in the archiving process

Advising and supporting teams on physical move

The Data Quality team are responsible for:-

Auditing health records filing systems and identifying those that do not conform to the approved filing system

The Services Leads and Managers are responsible for:-

Supporting the approved filing system

Ensuring that staff within their area conform to the approved filing process

Staff are responsible for:-

Using the approved filing method once it is implemented in their area


Working with the appropriate people in order to facilitate the move to the approved filing system

Approved Filing SystemIn order to comply with the appropriate legislation one standard for filing should be adopted by all services within LCH.However, due to variety of services it has been agreed and formerly recorded that two systems will be used.

Children Services will use a Date of Birth (DOB) filing system. This will organise children in their DOB order using the format DD/MM/YYYY.

All other clinical services that have patient records will use a strict alphabetical system based on the patient’s name. This will use Surname, Forename as the basis. For multiple patients with an exact same name e.g. Smith, John then these records will use DOB as the secondary filing method i.e. Smith John, 01/07/1945 will be filed before Smith John 10/05/1947.

Patients with records for multiple services will have their records stored together i.e. the records for District Nursing will be placed in the same suspended folder as those for Podiatry. The records will still remain as separate and not merged in but will be housed together.

This filing system will be implemented per building as services move around and as dictated by any other changes or time permitting.

References:-National Health Services Litigation Authority http://www.nhsla.com/Pages/Home.aspx

Care Quality Commission http://www.cqc.org.uk/

Records Management - NHS Code of Practice http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/I nformationpolicy/Recordsmanagement/index.htm


Appendix – exceptions to approved filing system

Any service that wishes to request to file outside of the guidelines must do so via the Records Management Sub Group. Requests will only be approved if a justifiable reason is provided.

The following services have had exception approved:

Offender Health – in order to comply with both Ministry of Justice and Department of Health legislation the Offender Medical Records are filed in alphabetical order of surname and then in numerical and alpha order e.g. Mr Blogs A1234AB/ A1234AC


Appendix G

Liverpool Community Health NHS Trust Board Meeting Date of meeting:

Title of Report Corporate Records Management and Audit

Agenda item:

Reason for the report to be presented to Board:

Approve Discuss

For notingPlease specify

Approve Board report number:

Responsible Director Job Title

TBC

Author Job Title

Samuel Curtis Deputy Records and Child Health Manager

Date report written – 03/09/2015

Recommendation/Action required by Board Paper once completed will contain the recommendations

if required

Engagement with patients/public/partner

N/A

Link to strategic objectivesLink to Board Assurance Framework – what assurance is provided to the Board?

Assurance of effective corporate documentation management

Does this report mitigate a risk held on the corporate risk

N/A

Resource Implications None – business as usual processes for records management

Has an Equality Analysis been completed?

N/A

Are there any legal or regulatory implications, including CQC?

To comply with IGT 601

Link to NHS Constitution N/AWhich Committees have received this

None as of yet will be reported to Health Care Governance Sub Committee

List of appendices Appendix A – DoH Records Management Code of Practice Corporate Record RetentionsAppendix B – Record Team Responsibilities and Audit Schedule

Publication: No – internal review If exempt Internal record


Is this report exempt from public disclosure?

please specify reason.

review

1. Executive Summary

Introduction

The term `corporate records’ means all other records which are not health records and that are held and used by employees of Liverpool Community Health (LCH), the public have a right to access corporate records and information, subject to certain exemptions, under the Freedom of Information Act 2000.

The regular review of records management process is important to ensure that processes remain appropriate given changes in statutory requirements e.g. DPA and FOI. Regular review of records management processes are important to ensure that not only the processes remain applicable but also that the controls within the processes are effective and are adhered to.

2. Background

Storage of records

The Department of Health Records Management Code of Practice provides guidance for all NHS records which includes corporate records e.g. human resources, finance, estates, supplies etc. Corporate documents e.g. minutes of meetings, policies, and briefing papers should be of a standard design.

Corporate documents should be created electronically and stored on the shared network or the Staff Information Resource Site (SIRS) and not on local drives. They should be easily accessible, with a system of version control in place. If records/papers are held in paper format they should be grouped in a logical structure to enable quick and efficient filing and retrieval of information. Suitable storage areas should be used to ensure that records/papers remain accessible and usable throughout their life cycle. Adequate security measures should be in place for both paper and electronic records/papers. They should be appropriately marked with the retention period. The Records Management Sub Group will support with on-going corporate records audits. The Records Management Sub Group reports formally to the Health Care Governance Sub Committee

Retention


Part 2 of the Records Management Code of Practice contains retention periods for both health corporate records. Records, both paper and electronic, should not be kept for longer than necessary. For a copy of the full document, please see the Records Management section of the LCH Intranet or Appendix A for the Corporate Retention periods

3. Current Position

Aim

To develop a comprehensive corporate records management programme and gain formal commitment to support the process and delegate responsibility for carrying it out to the appropriate member of staff.

Objectives

The records programme and audit cycle will enable LCH to:

Ensure corporate record retention periods are in line with the Records Management: NHS Code of Practice

Identify the location of records to assist the organisation to respond promptly to FOI requests for information

Determine the use made of each category of corporate record Determine whether duplicate records exist Determine whether it is necessary to retain the record Assess current and future records storage requirements Identify record creation and disposal concerns Identify the department responsible for creation, use and management of each

record collection Create an information asset register Identify any information security concerns

Other objectives of the records programme will be to ensure that LCH has complete and accurate corporate records to: Enable internal and external inventory, e.g. Audit Commission financial audits Protect the legal rights of LCH, its employees, its patients and third parties Provide authentication so that actions may confidently be taken on reliable information

Timescales

The key corporate areas will be surveyed in the first year of the programme:

Finance department Human resources department Estates department

Actions from the audit will be put in place during 2015/16 and reported to the responsible committee via the Records Management Sub Group. During the second year of the


programme, the 4 clinical localities will be surveyed e.g. Liverpool Central, Liverpool Matchworks etc.

Accountability and Governance

The Director of Finance as current Senior Information Risk Officer (SIRO) and Medical Director are the current Board members with overall responsibility for corporate records management. The Records and Information Governance Manager is the operational lead and will coordinate the programme across LCH. The Information Governance team will provide support in reporting progress for the requirements of the annual IG Toolkit return.

Appropriate direction, standards and training will be available to staff to ensure that each employee was aware of record management requirements.

Audit Process

The audit process will consist of the following:

Findings RisksRecommendations Action plan

Weak areas highlighted by the audits will also inform future training.

Records Inventory

A records inventory will be conducted to enable LCH to:

See where paper and electronic records are stored, Assess the general condition of stored paper records, and Obtain an overview of the types of information captured in the

record. Questionnaires and/or interviews will be used to gather detailed

data e.g.:

Who “owns” the record? How old is the record, i.e. what are the covering dates? Is it still in use? Is it of historical interest?

A records inventory survey template will be produced to enable departments to gather data.

It might be necessary to carry out follow-up interviews once the records inventory survey results have been returned to the team co-ordinating the work.

A representative sample of the categories of record created by each chosen area will be tracked through the various departments and personnel that handle it, with particular


emphasis on the type of information, what it is used for and, if it is passed on, who it is transferred to.

Shared Network

LCH are committed to the on-going review of both clinical and corporate records in keeping with national standards outlined in guidance such as the Information Governance Toolkit.The redesign of the existing shared network drive (L Drive) folder structure is essential to the management of the Trust’s corporate records and to provide assurance that compliance with legislation is being met. Key objectives are outlined within the Shared Network Drive and Corporate document that clearly identifies the project to manage corporate information.

To outline a generic and consistent approach to the management of folders on the LCH L Drive. The process will introduce an agreed naming convention to folders and set security groups.

To reduce the top level folders that are current on the existing shared drive

This standardised procedure will be managed by the Records Management Team who will facilitate and audit any future folder design.

To ensure that all LCH corporate documentation is housed and managed on the L Drive thus negating the need to save information on the private network drive (F Drive.)

To provide guidance on NHS corporate documentation and the retentions in which corporate documents are governed.

To support with efficient and effective document retrieval.

4. Conclusion

Corporate Records Management of the highest standard is a vital asset which supports the daily functions and operations of Liverpool Community Health NHS Trust. Information is essential for the delivery of high quality delivery of service and the organisation and as such must be correctly recorded, correctly version controlled and easily accessible when needed.

5. Recommendation

That LCH endorse the audit tool, schedule and that this document now align to the existing Records Policy for LCH.


TYPE/SUBTYPE OF RECORD MINIMUM RETENTION PERIOD DERIVATION FINAL ACTIONAccident forms (see also Litigation dossiers) 10 years Destroy under

confidential conditions

Accident register (Reporting of Injuries, Diseases and Dangerous Occurrences register) – see also Incident forms

10 years Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (reg. 7); Social Security (Claims and Payments) Regulations (reg. 25)

Destroy under confidential conditions

Adoption records (i.e. administrative records relating the adoption process)

75th anniversary of the date of birth of the child to whom it relates or, if the child dies before attaining the age of 18,15 years beginning with the date of the 18th birthday

Children and Young Persons Arrangements for Placement of Children (General) (Regulations 1991,SI 1991,No. 890 regs. 8, 9, 10 –children’s records) Adoption Regulations 2004(reg. 34)


Advance letters (eg DH guidance) 6 years DestroyAgendas of board meetings, committees, sub-committees (master copies, including associated papers)

30 years See note 1

Agendas (other) 2 years Destroy under confidential conditions

Agreements (see Contracts)


TYPE/SUBTYPE OF RECORD MINIMUM RETENTION PERIOD DERIVATION FINAL ACTION

Ambulance Records – Administrative (i.e. records containing non-clinical details only)e.g. records of journeys

2 years from the end of the year to which they relate Destroy under confidential

conditions

Annual/corporate reports 3 years See note 1

Appointment Records (GP) 2 years (Provided that any patient-relevant information has been transferred to the patient record)At the end of the 2 year retention period GP practices should consider if there is an ongoing administrative need to keep the records/books for longer. If there IS an ongoing need to retain these records/books, then a further review date should be set (either 1 or 2 more years)

Destroy under confidential conditions – once a decision has been made that there is no ongoing administrative need to retain the records.



Assembly/Parliamentary questions, MP enquiries 10 years As these documents include all information provided by the organisation in response to a PQ (e.g. background note to the Minister or the Minster may amend the response) all of which may not be used in the response and therefore it will not be in the public domain on House of Commons records they must be destroyed under confidential conditions.


Audit Records (e.g. Organisational Audits, Records Audits, Systems Audits) – Internal & External in any format (paper, electronic etc)

2 years from the date of completion of the audit


Business plans, including local delivery plans 20 years Destroy

Catering forms 6 years Destroy under confidential conditions

Close circuit TV images 31 days Information Commissioner’s Code of Conduct Erase permanently


Commissioning decisions Appeal documentation– Decision documentation –

6 years from date of appeal – decision6 years from date of decision –


Complaints (See also litigation dossiers)Correspondence, investigation and – outcomes Returns made to DH –

8 years from completion of action– Files closed annually and kept for – 6 years following closure NB: Current policy on the handling of complaints is under review and further guidance will be issued in due course


Copyright declaration forms (Library Service) 6 years Copyright, Designs and Patents Act 1988


Data Input Forms (where the data/information has been input to a computer system)

2 years Destroy under confidential conditions

Diaries (office) 1 year after the end of the calendar year to which they refer


Exposure monitoring records 5 years from the date the record was made

Control of Substances Hazardous to Health Regulations 2002 (reg. 10(5))


’Find-a-Doc’ records (kept by PCT’s)contact sheets and letters– assignment cases/letters– records of negotiations with GMS contract – managers re: patient registration with a GP

6 months2 years2 years


Flexi working hours (personal record of hours actually worked)

6 months Destroy under confidential conditions


Freedom of Information requests 3 years after full disclosure;10 years if information is redacted or the information requested is not disclosed


GMS1 forms (registration with GP) 3 years Destroy under confidential conditions

Health and safety documentation 3 years Destroy under confidential conditions

History of organisation or predecessors, its organisation and procedures (eg establishment order)

30 years See note 1

Hospital (trust) services i.e. service that the Trust provides e.g. catering, hotel services

10 years Destroy

Incident forms 10 years Destroy under confidential conditions

Indices (records management) Registry lists of public records marked for permanent preservation, or containing the record of management of public records – 30 years File lists and document lists where public records or their management are not covered – 30 years

See note 1Destroy under confidential conditions

Laundry lists and receipts 2 years from completion of audit Destroy under confidential conditions

Library registration forms 2 years after registration Destroy


Litigation dossiers (complaints including accident/incident reports)Records/documents relating to any form of litigation

10 years Where a legal action has commenced, keep as advised by legal representatives


Manuals – policy and procedure (administrative and clinical, strategy documents)

10 years after life of the system (or superseded) to which the policies or procedures refer

Destroy (policy documents may have archival value– see note 1)

Maps Lifetime of the organisation See note 1

Meetings and minutes papers of major committees and sub-committees (master copies)

30 years See note 1

Meetings and minutes papers (other, including reference copies of major committees)



Mental Health Act Administration Records 5 years NB There is no obligation to treat this type of mental health record as being part of a patient’s health record. There may, however, be exceptions, such as where they are required to be kept as evidence in actual or expected litigation or where they are needed by a healthcare professional in order to provide healthcare. Each healthcare practitioner has discretion as to the information which s/he wishes to include as part of a patient

HC(91)29 (NHS)SI 2001/3869,reg.47 (Independent Sector)



record. If in any particular case a healthcare practitioner requires a document which forms part of the mental health act administration record to be included in a patient’s record (because he or she regards it as relevant to the patient’s healthcare), it should then be regarded as part of the patient’ health record

Mortgage documents (acquisition, transfer and disposal)

6 years after repayment See note 1

Nominal rolls 6 years (maximum) Destroy under confidential conditions



Papers of minor or short-lived importance not covered elsewhere,

eg: advertising matter

– covering letters

– reminders

– letters making appointments

– anonymous or unintelligible letters

– drafts

– duplicates of documents known to be

– preserved elsewhere (unless they have important minutes on them)indices and registers compiled for

– temporary purposes routine reports

– punched cards

– other documents that have ceased to be of

– value on settlement of the matter involved

2 years after the settlement of the matter to which they relate


Patient Advice & Liaison Service (PALS) records 10 years after closure of the case Destroy under confidential conditions

Patient information leaflets 6 years after the leaflet has been superseded

See note 1



Patients’ property books/registers (property handed in for safekeeping)

6 years after the end of the financial year in which the property was disposed of or 6 years after the register was closed


Patient Surveys (re access to services etc) 2 years Destroy under confidential conditions

Phone Message Books 2 years NB Any clinical information should be transferred to the patient health record


Police Statements (made in the context of Accident and Emergency episodes. Statements are requested by the Police to the A&E staff in relation to alleged injuries of or by patients coming through A&E)

10 years (congruent retention period as Incident Forms)


Press cuttings 1 year Destroy (where bound volumes exist, see note 1)

Press Releases 7 years see note 1

Project files (over £100,000) on termination, including abandoned or deferred projects

6 years See note 1

Project files (less than £100,000) on termination 2 years Destroy under confidential conditions



Project team files (summary retained) 3 years Destroy under confidential conditions

Public Consultations e.g. about future provision of services


Quality and Outcomes Framework (QOF) documents (GP Practice records)


Quality assurance records (eg Healthcare Commission, Audit Commission, King’s Fund Organisational Audit, Investors in People)


Receipts for registered and recorded mail 2 years following the end of the financial year to which they relate


Records documenting the archiving, transfer to public records archive or destruction of records

30 years See note 1

Records of custody and transfer of keys 2 years after last entry Destroy under confidential conditions

Reports (major) 30 years See note 1

Requests for access to records, other than Freedom of Information or subject access requests

6 years after last action Destroy under confidential conditions



Requisitions 18 months Destroy under confidential conditions

Research ethics committee records 3 years from date of decision See note 1

Serious incident files 30 years See note 1

Specifications (eg equipment, services) 6 years Limitation Act 1980 Destroy under confidential conditions

Statistics (including Korner returns, contract minimum data set, statistical returns to DH, patient activity)

3 years from date of submission Destroy

Subject access requests (DPA and AHR)– records of requests

3 years after last action Destroy under confidential conditions

Surgical appliances forms AP 1, 2, 3 and 4 2 years from completion of audit Destroy under confidential conditions

Time sheets (relating to a Group or Departmente.g. Ward where the timesheets are kept as a tool to manage resources, staffing levels)



BIOMEDICAL ENGINEERING

Sterilix Endoscopic Disinfector Daily Water Cycle Test,

11 years Consumer Protection Act 1987



Sterilix Endoscopic Disinfector Daily Water Purge Test, Nynhydrin Test

11 years Consumer Protection Act 1987



ESTATES/ENGINEERING

Buildings and engineering works, including major projects abandoned or deferred – key records (eg final accounts, surveys, site plans, bills of quantities)

30 years See note 1

Buildings and engineering works, including major projects abandoned or deferred – town and country planning matters and all formal contract documents (eg executed agreements, conditions of contract, specifications, ’as built’ record drawings, documents on the appointment and conditions of engagement of private buildings and engineering consultants)

30 years See note 1

Buildings – papers relating to occupation of the building (but not health and safety information)

3 years after occupation ceases Construction Design Management Regulations 1994


Deeds of title Retain while the organisation has ownership of the building unless a Land Registry certificate has been issued, in which case the deeds should be placed in an archiveIf there is no Land Registry certificate, the deeds should pass on with the sale of the building

See note 1



Drawings – plans and buildings (architect signed, not copies)

Lifetime of the building to which they relate

See note 1

Engineering works – plans and building records Lifetime of the building to which they relate

See note 1

Equipment – records of non-fixed equipment, including specification, test records, maintenance records and logs

11 years If the records relate to vehicles (ambulances, responder cars, fleet vehicles etc) and where the vehicle no longer exists, providing there is a record that it was scrapped, the records can be destroyed

Consumer Protection Act 1987


Inspection reports (eg boilers, lifts) Lifetime of installation If there is any measurable risk of a liability in respect of installations beyond their operational lives, the records should be retained indefinitely

See note 1

Inventories of furniture, medical and surgical equipment not held on store charge and with a minimum life of 5 years

Keep until next inventory See note 1

Inventories of plant and permanent or fixed equipment

5 years after date of inventory See note 1

Land surveys/registers 30 years See note 1


Leases – the grant of leases, licences and other rights over property

Period of the lease plus 12 years Limitation Act 1980 Destroy under confidential conditions


Maintenance contracts (routine) 6 years from end of contract Destroy under confidential conditions

Manuals (operating) Lifetime of equipment Review if issues (eg HSE) are outstanding

Medical device alerts Retain until updated or withdrawn (check MHRA website)

www.mhra.gov.uk Destroy under confidential conditions

Photographs of buildings 30 years See note 1

Plans – building (as built) Lifetime of building May have historical value – see note 1

Plans – building (detailed) Lifetime of building May have historical value (see note 1)

Plans – engineering Lifetime of building See note 1

Property acquisitions dossiers 30 years See note 1

Property disposal dossiers 30 years See note 1

Radioactive waste 30 years Radioactive Substances Act 1993

See note 1

Site files Lifetime of site See note 1

Structure plans (organisational charts) i.e. the structure of the building plans

Lifetime of building See note 1


Surveys – building and engineering works Lifetime of building or installation See note 1


FINANCIAL

Accounts – annual (final – one set only) 30 years See note 1

Accounts – minor records (pass books, paying-in slips, cheque counterfoils, cancelled/discharged cheques (for cheques bearing printed receipts, see Receipts), accounts of petty cash expenditure, travel and subsistence accounts, minor vouchers, duplicate receipt books, income records, laundry lists and receipts)

2 years from completion of audit Destroy under confidential conditions

Accounts – working papers 3 years from completion of audit Destroy under confidential conditions

Advice notes (payment) 1.5 years Destroy under confidential conditions

Audit records (internal and external audit) – original documents


Audit reports – internal and external (including management letters, value for money reports and system/final accounts memoranda)

2 years after formal completion by statutory auditor


Bank statements 2 years from completion of audit Destroy under confidential conditions



Banks Automated Clearing System (BACS) records

6 years after year end Destroy under confidential conditions

Benefactions (records of) 5 years after end of financial year in which the trust monies become finally spent or the gift in kind is accepted. In cases where the Benefaction Endowment Trust fund/capital/interest remains permanent, records should be permanently retained by the organisation

See note 1

Bills, receipts and cleared cheques 6 years Destroy under confidential conditions

Budgets (including working papers, reports, virements and journals)


Capital charges data 2 years from completion of audit Destroy under confidential conditions

Capital paid invoices (see Invoices)

Cash books 6 years after end of financial year to which they relate

Limitation Act 1980 Destroy under confidential conditions


Cash sheets 6 years after end of financial year to which they relate



Contracts – financial Approval files – 15 years Approved suppliers lists – 11 years


Contracts – non-sealed (property) on termination

6 years after termination of contract Limitation Act 1980 Destroy under confidential conditions

Contracts – non-sealed (other) on termination 6 years after termination of contract Limitation Act 1980 Destroy under confidential conditions

Contracts – sealed (and associated records) Minimum of 15 years, after which they should be reviewed

See note 1

Contractual arrangements with hospitals or other bodies outside the NHS, including papers relating to financial settlements made under the contract (eg waiting list initiative, private finance initiative)

6 years after end of financial year to which they relate


Cost accounts 3 years after end of financial year to which they relate


Creditor payments 3 years after end of financial year to which they relate



Debtors’ records – cleared 2 years from completion of audit Destroy under confidential conditions

Debtors’ records – uncleared 6 years from completion of audit Destroy under confidential conditions


Demand notes 6 years after end of financial year to which they relate


Estimates, including supporting calculations and statistics



Excess fares 2 years after end of financial year to which they relate


Expense claims, including travel and subsistence claims, and claims and authorisations



Fraud case files/investigations 6 years Destroy under confidential conditions

Fraud national proactive exercises 3 years Destroy under confidential conditions


Funding data 6 years after end of financial year to which they relate


General Medical Services payments 6 years after year end Destroy under confidential conditions

Invoices 6 years after end of financial year to which they relate


Ledgers, including cash books, ledgers, income and expenditure journals, nominal rolls, non-exchequer funds records (patient monies)




Non-exchequer funds records (i.e. funding received by the organisation that does not directly relate to patient care eg charitable funds)

30 years Company charities are required by company law to keep their accounts and accounting records for at least three years but the Charity Commission recommends that they be kept for at least 6 years. The majority of non-company charities must keep their accounts and accounting records for six years (Part VI Charities Act 1993).

Although technically exempt from the Public Records Act, it would be appropriate for authorities to treat these records as if they were not exempt

Patient Monies (i.e. smaller sums of donated money)



PAYE records 6 years after termination of employment


Payments 6 years after year end Destroy under confidential conditions

Payroll (ie list of staff in the pay of the organisation)

6 years after termination of employment

Destroy underconfidentialconditionsForsupera nnuationpurposes,organisations may wish to retain such records until the subject reaches benefit age

Positive predictive value performance indicators


Private Finance Initiative (PFI) 30 years See note 1


Receipts 6 years after end of financial year to which they relate


Salaries (see Wages)


Superannuation accounts 10 years Destroy under confidential conditions

Superannuation registers 10 years Destroy under confidential conditions

Tax forms 6 years Destroy under confidential conditions

Transport (staff pool car documentation) 3 years unless litigation ensues Destroy under confidential conditions

Trust documents without permanent relevance/not otherwise mentioned


Trusts administered by Strategic Health Authorities (terms of)

30 years See note 1

VAT records 6 years after end of financial year to which they relate




Wages/salary records 10 years after termination of employment

Destroy under confidential conditions For superannuation purposes organisations may wish to retain such records until the subject reaches benefit age.


IM & T

Documentation relating to computer programmes written in-house

Lifetime of software Destroy under confidential conditions

Software licences Lifetime of software Destroy under confidential conditions

TYPE/SUBTYPE OF RECORD

MINIMUM RETENTION PERIOD DERIVATION FINAL ACTION

OTHER

Chaplaincy records 2 years May have archival value – see note 1

Contractor Applications (Doctors, Dentists, Opticians & Pharmacists)

6 years after end of contract for approvals6 years for non-approvals.




Contractor Records (e.g. Ophthalmic Opticians, Ophthalmic Medical Practitioners, Pharmacists, Pharmacy Premises, General Optical Council amendments to the register, Previous Pharmacy rotas and supporting information (prior to 2005 – new regulations), Copies of previous Pharmacy and Ophthalmic local lists, Correspondence relating to pharmacies supplying oxygen and visiting Residential/Nursing homes (prior to new regulations)

7 years NHS (General Ophthalmic Services) Regs 1986: A contractor shall keep a proper record in respect of each patient to whom he provides general ophthalmic services, giving appropriate details of sight testing. Subject to paragraph 8(5) a contractor shall retain all such records for a period of seven years, and shall during that period produce them when required to do so by a Primary Care Trust or the Secretary of State. Follow link below for more detailhttp://www.dh.gov.uk/ass etRoot/04/10/12/42/04101242. pdf




Doctors Postgraduate Educational Allowance/ Personal Development Plan files and supporting general correspondence – Records kept by PCT’s

GP Seniority (prior to 2004 – new regulations)

NHS (General Ophthalmic Services) Regs 1986:

A contractor shall keep a proper record in respect of each patient to whom he provides general ophthalmic services, giving appropriate details of sight testing.

Subject to paragraph 8(5) a contractor shall retain all such records for a period of seven years, and shall during that period produce them when required to do so by a Primary Care Trust or the Secretary of State.

Follow link below for more detail

http://www.dh.gov.uk/assetRo ot/04/10/12/42/04101242.pdf


Family Health Service Appeals Authority tribunal and case files

Case files – 10 years Decision records – until individual’s 80th birthday

See note 1Destroy under confidential conditions


GP retirements/moved away 6 years after individual leaves service, at which time a summary of the file must be kept until the individual’s 70th

See note 1


birthday

Research and development (organisation)i.e. all the organisation’s records associated with research and development and not individual trial records or information on patients.

30 years Medical Research Council See note 1


PERSONNEL/HUMAN RESOURCES

NB Both medical staff records and agency locums staff records should be treated as personnel records and retained accordingly.

Consultants (records relating to the recruitment of)

5 years NHS (Appointment of Consultants) Regulations, good practice guidelines, page 11, para. 5.3 http://www.dh.gov.uk/assetR oot/04/10/27/50/04102750.pd f


CVs for non-executive directors (successful 5 years following term of office Destroy under confidential


applicants) conditions

CVs for non-executive directors (unsuccessful applicants)


Duty rosters i.e. organisation or departmental rosters, not the ones held on the individual’s record.

4 years after the year to which they relate Destroy under confidential

conditions

Industrial relations (not routine staff matters), including industrial tribunals


Job advertisements 1 year Destroy


Job applications (successful) 3 years following termination of employment


Job applications (unsuccessful) 1 year Destroy under confidential conditions

Job descriptions 3 years Destroy under confidential conditions

Leavers’ dossiers 6 years after individual has left Summary to be retained until individual’s 70th birthday or until 6 years after cessation of employment if aged over 70 years at the time. The summary should contain everything except attendance books, annual leave records, duty rosters, clock cards, timesheets, study leave

The 6 year retention period is to take into account any ET claims, or EL claims that may arise after the employee leaves NHS employment, requests for information from the NHS pensions agency etc. Claims of this nature can include periods of up to 6

Destroy under confidential conditions See note 1


applications, training plans years or more prior to the claim and where evidence could be needed from a number of sources, it is appropriate to retain as much as possible from the original file.

Letters of appointment 6 years after employment has terminated or until 70th birthday, whichever is later



Nurse training records (from hospital-based nurse training schools prior to the introduction of academic-based training)

30 years See note 1

Pension Forms (all) 7 years HMRC Technical Pension Notes for registered pension schemes under regulation 18 of SI2006/567 – ‘RPSM12300020 – SchemeAdministrator Information Requirements and Administration for General Retention of Records’



Personnel/human resources records –major (eg personal files, letters of appointment, contracts, references and related correspondence, registration authority forms, training records, equal opportunity monitoring forms (if retained)) NB Includes locum doctors

6 years after individual leaves service, at which time a summary of the file must be kept until the individual’s 70th birthday Summary to be retained until individual’s 70th birthday or until 6 years after cessation of employment if aged over 70 years at the time. The summary should contain everything except attendance books, annual leave records, duty rosters, clock cards, timesheets, study leave applications, training plans

The 6 year retention period is to take into account any ET claims, or EL claims that may arise after the employee leaves NHS employment, requests for information from the NHS pensions agency etc. Claims of this nature can include periods of up to 6 years or more prior to the claim and where evidence could be needed from a number of sources, it is appropriate to retain as much as possible from the original file.

See note 1


Personnel/human resources records – minor (eg attendance books, annual leave records, duty rosters (i.e. duty rosters held on the individual’s record not the organisation or departmental rosters), clock cards, timesheets (relating to individual staff members)) NB Includes locum doctors

2 years after the year to which they relate


Staff car parking permits 3 years Destroy under confidential conditions

Study leave applications 5 years Destroy under confidential conditions


Timesheets (for individual members of staff) 2 years after the year to which they relate NB Timesheets (for all individuals including locum doctors) held on the personnel record are minor records – retain for 2 years. Timesheets held elsewhere – i.e. on the ward retain for 6 months (as the master timesheet is held on the personnel file)


Training plans 2 years Destroy under confidential conditions


PURCHASING/SUPPLIES

Approval files (contracts) 6 years after end of the year the contract expired


Approved suppliers lists 11 years Consumer Protection Act 1987


Delivery notes 2 years after end of financial year to which they relate


Products (liability) 11 years Consumer Protection Act 1987


Stock control reports 18 months Destroy under confidential conditions


Stores records – major (eg stores ledgers) 6 years Destroy under confidential conditions

Stores records – minor (eg requisitions, issue notes, transfer vouchers, goods received books)



Supplies records – minor (eg invitations to tender and inadmissible tenders, routine papers relating to catering and demands for furniture, equipment, stationery and other supplies)


Tenders (successful) Tender period plus 6 year limitation period


Tenders (unsuccessful) 6 years Limitation Act 1980 Destroy under confidential conditions


Appendix H


Record Keeping Audit Process


Version Date Issued Changes Owner1.0 December 2013 New Process Jenni Delea

Version Number 1.0Approving Body RMSGDate of Approval 18.12.2013Ratified ByIssue Date 24.02.2014Review DateTarget Audience Organisation WideLead Director

Contents PageBackground 3Purpose 3Contacts 3Process 4Appendix One – Invitation E-mail 5Appendix Two – Reminder E-mail 6


1 Background

Record keeping of the highest standard is a vital asset which supports the daily functions and operations of Liverpool Community Health NHS Trust (LCH). Information is essential for the delivery of high quality evidence based health care, delivery of service and the organisation and as such must be correctly recorded, regularly updated and easily accessible when needed.

LCH are committed to the on-going review of both clinical and corporate records in keeping with national standards outlined in guidance such as the Information Governance Toolkit.Requirement 11-404 is for a multi professional audit of clinical records across all specialties to be under taken, with a minimum of 50% annually.

2 Purpose of Process

To outline a generic and consistent approach to conducting annual record keeping audits within LCH. The process relates to routine audits any ad hoc requests will be completed outside of this procedure. This standardised procedure will be managed by the Records Management Team.

Links throughout all Localities within LCH and partner organisations will be maintained by the Records Management Team via this process and through the Records Management Sub Group (RMSG).

3 Contacts – Records Management Team

Name Designation TelephoneSam Curtis Deputy Child Health & Records

Manager295 3242

Jenni Delea Records Co-ordinator 295 3264Rob Ruddick Records Co-ordinator 295 3265Michelle Cullen Records Team Supervisor 295 3263Neil Hale Senior Records Clerk 295 3263Martin Carter Records Clerk 295 3263Pat Lloyd Records Clerk 295 3263Jackie Mulholland Records Clerk 295 3263Mandy Woods Records Clerk 295 3263


4 Process Overview


Appendix One - Standard E-mail Templates

Standard e-mail template notifying services of planned visit by Records Team

From Records Management InboxTo Service Managers NameCC Any relevant personnel in service

and lead analystSubject line of message [insert service] Record Keeping Audit

Standard Message

Dear INSERT MANAGERS NAME,

As part of the LCH annual record keeping audit schedule the Records Team will be visiting insert service at insert location on insert date.

The purpose of this visit will be to conduct an audit across a 5% sample of records within the team in order to ensure compliance with the LCH Records Management Policy and IG Toolkit requirements.

We would be grateful if you could hold this date in your diary and provide us with a named lead in the service who can contact with a reminder and some further details one week prior to the audit. The reminder will also include the sample list, which is generated by the Performance & Intelligence lead analyst for your area, the records for all the listed patients will be required.

If there is anything you wish to discuss in the meantime please do not hesitate to contact us.

Many Thanks



Appendix Two - Reminder E-mail Templates

Standard e-mail template notifying services of planned visit by Records Team

From Records Management InboxTo Service Managers NameCC Any relevant personnel in service

and lead analystSubject line of message [insert service] Record Keeping Audit

Standard Message

Dear INSERT MANAGERS NAME,

Further to our email on insert date please accept this email as a reminder of the record keeping audit that is scheduled for insert service at insert location on insert date.

The records team staff members attending will be insert names and they will be arriving at approximately insert time. We would be grateful if you can have the records for the patients listed in the attached sample list available for them to audit.

Following on from this audit the results will be analysed and you will be sent feedback on the results in a month’s time. If required the Records Team will work with you on an action plan to improve on any areas highlighted as part of this audit.

If there is anything you wish to discuss in the meantime please do not hesitate to contact us.

Many Thanks



Policy Number