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

3. 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

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

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

6. 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

7. 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

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

9. 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.

10. 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

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

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

13. 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

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

15. 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

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

17. 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

18. 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

19. Scanning Scanning paper records can reduce storage requirements

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

21. 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

22. 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.

23. 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

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

25. Further Guidance and useful links DH: Confidentiality NHS Code of Practice DH: Records Management NHS Code of Practice The Data Protection Act 1998 The Freedom of Information Act 2000 The IG Policy Team Website Records Management Roadmap The Department of Health website Information Commissioners Office website (more information and guidance on FOI and DPA)