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Records Management and the NHS Code of Practice (Foundation)

Records Management and the NHS Code of Practice (Foundation). Information Governance Policy Team NHS Connecting for Health. Key Learning Points. What is Records Management? What is a record? Who is responsible for records? The Records Management: NHS Code of Practice

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Records Management and the NHS Code of Practice (Foundation)

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  1. Records Management and the NHS Code of Practice(Foundation) Information Governance Policy Team NHS Connecting for Health

  2. Key Learning Points What is Records Management? What is a record? Who is responsible for records? The Records Management: NHS Code of Practice Benefits of records and records management The Records Lifecycle

  3. What is Records Management? • Systematic management of all records • Paper and electronic records

  4. What is a record? Records document each and every activity They are the organisation’s memory

  5. Types of Records • Health records • X-rays • Administrative records • Photographs, slides, and other images • Microfilm • Audio and video tapes, cassettes, CD-ROM • Diaries • E-mails, text messages • Etc, etc, etc

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

  7. The Records Management: NHS Code of Practice A guide to: • Standards of best practice • Legal requirements

  8. What does the Code of Practice replace? • HSC 1999/053 – For the Record • HSC 1998/217 – Preservation, Retention and Destruction of GP General Medical Services Records Relating to Patients • HSC 1998/153 – Using Electronic Patient Records in Hospitals: Legal Requirements and Good Practice.

  9. Guidance aims • Establish a Records Management framework • Clarify legal obligations • Detail required actions • Explain the requirement for permanent preservation • Set out recommended minimum retention periods • Where to find further information

  10. Records are a valuable resource! They support: • Patient care • Administrative decision making • Legal requirements • Clinical audits • Patient choice

  11. Benefits of Records Management • Better use of space • Better use of time • Improved control of resources • Compliance with legislation • Reduce costs

  12. Create Use Retention Appraisal Disposal Record Lifecycle Any record created by an individual, up to its disposal, is a public record and subject to Information Requests Close Record Be aware Monitor Control

  13. Record Creation Each function must document all activities and ensure records are: • Accurate • Complete • Easy to find and retrieve Credible and Authoritative

  14. Information Quality Assurance Managers must ensure that staff are trained What? How? Why? • What to record • How to record • Why to record AND How to validate & update records

  15. ing Record Keeping What records are held, where and who manages them? Records Inventory Survey

  16. Records Inventory Survey A stepped approach is recommended

  17. Record Maintenance • Control record movement and location • Storage areas should be clean and tidy • Stores should be secure • Secondary storage for non-current records • Contingency/Business Continuity Plans

  18. Scanning Scanning paper records can reduce storage requirements

  19. Scanning However: • Costs of initial conversion • Consult with The National Archives • Protect the evidential value

  20. Disclosure and Transfer of Records Statutory provisions limit the disclosure of records • Freedom of Information Act 2000 • Data Protection Act 1998 • The Abortion Regulations 1991 • Crime and Disorder Act 1998 • Public Records Act 1958

  21. Disclosure and Transfer of Records If you have any concerns, contact, as appropriate, your organisation’s: • Caldicott Guardian; • Information Security Officer; • Data Protection Officer; • Health Records Manager; or • Records Manager.

  22. Retention and Disposal Arrangements All organisations should have Record Retention and Disposal policies to ensure records are annually selected for: • Secondary storage (eg off-site or scanned etc) • Permanent archival preservation • Destruction

  23. Record Destruction • Records must be destroyed in a secure environment • Contractors must abide by Confidentiality Agreements • Maintain a register of the destruction of records

  24. Further Guidance and useful links

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