Health Records Management Practitioner

1. Health Records ManagementPractitioner Information Governance Policy Team NHS Connecting for Health

2. Key Learning Points • Responsibilities for health records • Record Lifecycle Management • Auditing current health records practices & procedures • Undertaking an records inventory survey of existing health records systems • Drafting/maintaining the organisation’s health records management policy • Drafting/maintaining the organisation’s health records management strategy & associated action plan • Raising awareness of the importance of health records management throughout your organisation

3. Responsibilities for Records ‘All individuals who work for an NHS organisation are responsible for any records which they create or use in the performance of their duties….. any record that an individual creates is a public record.’ Records Management: NHS Code of Practice There are therefore INDIVIDUAL, STATUTORY & MANAGERIAL responsibilities for all NHS records, including health records

4. Record Lifecycle Management Create Use Retention Appraisal Disposal Close Record Be aware Monitor Control

5. Information Requests Information Requests NHS records may be subject to information requests

6. Health Records Policies & Procedures • Procedure • Policy and Procedure manual • Key management tool • Basis for specific training

7. Auditing Health Records Policies & Procedures – The Audit Cycle • The audit cycle

8. Undertaking a Records Inventory Survey • Guidance has been produced to help those organisations that have not yet started to establish a records inventory or are still in the in the early stages of completing one • The guidance & a records inventory survey form are available in the records management roadmap www.connectingforhealth.nhs.uk/infogov/records and they are summarised in the following slides.

9. Practical Steps • A health records inventory is one component of the complete records inventory • It can be completed in 3 steps • Insert 3 step diagram

10. Distributing & Completing the inventory • Distributing & Completing the Inventory Forms • Aggregating the Inventory Form

11. Benefits of a Health Records Inventory#1 • Improves compliance with: • Records Management: NHS Code of Practice • IG Toolkit requirements • NHS Litigation Authority’s risk management standards • Standards for Better Health • Professional standards

12. Benefits of a Health Records Inventory#2 • Informs the Board’s Assurance Framework • Identifies managers and ‘owners’ • Identifies sharing arrangements • Identifies the format in which records are stored • Allows mapping to retention schedules • Ensures appropriate training • Identifies storage conditions • Identifies security arrangements

13. Keeping the Inventory Up to Date • The inventory needs to be accurate & kept up to date • Health records manager must keep the health records inventory up to date • Records management lead has responsibility for keeping the corporate inventory up to date

14. Health Records Management Policy A health records management policy applies to all types of health record regardless of the media on which they are held Its sets out a framework within which to develop specific policies and practices to ensure that health records are managed and controlled Model documentation is available in the records management roadmap

15. Aims of a Health Record Management Policy are available when needed can be accessed can be interpreted can be trusted can be maintained through time are secure are retained and disposed of appropriately staff are appropriately trained • To ensure that health records:

16. Drafting and maintaining a Health Records Management Strategy • The health records management strategy applies to all health records of all types regardless of the media on which they are held; • It should be an integral part of the organisation’s wider records management strategy and be compliant with the organisation’s records management policy. If the strategy and policy have not yet been written, model documentation is available in the records management roadmap

17. Aims of the Records Management Strategy • Responsibility and accountability • Record quality • Management • Security • Access • Audit • Training

18. Why do we need a Health Records Management Strategy? • To provide a robust baseline from which to move forward; • To identify how the management of health records is currently structured; • To identify what health records the organisation generates and how they are archived and stored; • To enable the organisation to meet existing and future demands for health records management; • To ensure that the organisation meets it’s legal and statutory obligations in respect of health records; • To help NHS organisations to improve the standard of health records management and to raise the profile of the service within the organisation.

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

20. The Planning Cycle

21. Where are we now?#1(Position Statement) • Results of baseline audit - list the types and numbers of records and locations where they are stored and who is responsible for managing them; • Describe environmental conditions; • Document security & access arrangements to storage areas;

22. Where are we now?#2(Position Statement) • Document retention periods for all types of records in line with the current retention schedule and indicate the organisation’s compliance status; • List existing policies & procedures including retention, weeding, archiving & destruction.

23. Developing the Action Plan(Identifying Goals & Objectives) • Is there a designated manager responsible for each collection of records? • Are you storing more records than necessary? • Is there sufficient storage space for them? • Are environmental conditions appropriate & safe? • Do you need additional storage? • Do you need to look at archiving solutions? • Are disposal & destruction arrangements appropriate?

24. Where do we want to be?(Goals & Objectives) Goals &objectives should be SMART • Specific • Measurable • Achievable • Realistic • Time-bound

25. Developing the Action Plan#1(How Are We Going To Get There?)Action Points • Identify tasks related to each of the goals and objectives:- • Specifytimescales • Specify resources required • Specify responsibility for action(s) • Quantify resources required & produce a business case to secure additional resources if necessary

26. Developing the Action Plan(How Will We Know What Progress We Are Making?)Monitoring Criteria • Determine monitoring criteria & timescales:- • Specify how progress will be monitored and when • Specify how progress will be reported • Schedule monitoring meetings aligned with the timescales & milestones in the strategic plan

27. The Health Records Management Strategy – Making it Happen • The strategy should:- • Contain a realistic action plan with achievable milestones and timescales for implementation; • Identify resources required to achieve the plan; • Identify possible risks, which may jeopardise the plan; • Have regular reviews of progress built in to it.

28. Keeping The Strategy Under Review • Review the strategy annually • Maintain close links with the IM&T & corporate records management strategies • Maintain close links with the IGT assessment process

29. Raising awareness of Health Records Management – Why? • To ensure that everyone knows who has the lead role for records management in the organisation • To ensure that all members of staff understand their personal responsibilities in respect of health records management • To ensure that issues and progress on health records management are routinely fed back to the Board

30. Further Guidance and useful links