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 Benefits of records and records management The Records Lifecycle

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

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

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

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

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

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

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

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

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

Record Lifecycle Any record created by an individual, up to its disposal, is a public record and subject to Information Requests CreateUseRetentionDisposalAppraisal Close Record Be awareControlMonitor

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

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

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

A stepped approach is recommended Non- Health Records Step 4Estates, IM&T, Other Step 3Administrative records, Purchasing & supplies Step 2Human Resources, Finance Health Records Step 1PAS or PAS- fed Clinical Systems Paper based, scanned, microform records etc. Standalone clinical systems Databases e.g. research

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

Scanning Scanning paper records can reduce storage requirements

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

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

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

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

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

Further Guidance and useful links Records Management: NHS Code of Practice RM NHS CoP Part 1.pdf RM NHS CoP Part 2.pdf Confidentiality NHS Code of Practice Confi Code Of Practice.pdf Data Protection Act 1998Data Protection Act 1998.htm Freedom of Information Act 2000 Freedom of Information The Department of Health - Policy and guidance.htm NHS IG Policy Team website (Find out more about IG) Information Governance (IG) Policy Website.htm Department of Health websiteDH home The Department of Health.htm

Records Management NHS Code of Practice (Foundation) Assessment Answer the questions to follow and if answered correctly you will qualify for a certificate of achievement to add to your personal portfolio.

Assessment 1.Which records management guidance was published by DoH in April 2006? 2.This guidance applies to paper records only: TRUE or FALSE 3.Put the following stages of a Record Lifecycle in the correct order: RETENTION, USE, CREATE, DISPOSAL, APPRAISAL 4.Who, other than your line manager, can you contact regarding the disclosure and transfer of records? 5.Records can be thrown in office waste paper baskets when no longer required: TRUE or FALSE

Assessment Answers 1.Records Management: NHS Code of Practice 2.FALSE: The guidance applies to both paper and electronic records 3.Create, Use, Retention, Appraisal, Disposal 4.Depending on your organisational structure the following should be approached for advice: Caldicott Guardian; Information Security Officer; Data Protection Officer; Health Records Manager; or Records Manager. 5.FALSE: records must be disposed of securely to ensure no unauthorised access