NON-CLINICAL RECORDS MANAGEMENT POLICY
Version / 7Name of responsible (ratifying) committee / Information Governance Steering Group
Date ratified / 13 November 2017
Document Manager (job title) / Information Governance Manager
Date issued / 09 January 2018
Review date / 08 January 2020
Electronic location / Management Policies
Related Procedural Documents / Information and Records Management Strategy, Records Retention and Disposal Policy, Clinical Records Management Policy, Procedural Documents Development & Management policy
Key Words (to aid with searching) / Records Management, Corporate Records, Retention, Disposal, Destruction, Filling
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author7 / 13/11/2017 / Removal of ‘c’ drives storage instructions & screenshots.
Minor changes to wording
Removal of Document Properties requirement
Removal of Retention, disposal & destruction guidance / E Armour
6 / 12/11/2014 / Update to Training Requirements (section 7) to reflect Essential Skills Handbook and e-assessment
Update to Monitoring Compliance section (9) to reflect requirements of the Information Governance Compliance Framework / J Taylor
CONTENTS
QUICK REFERENCE GUIDE
1.INTRODUCTION
2.PURPOSE
3.SCOPE
4.DEFINITIONS
5.DUTIES AND RESPONSIBILITIES
6.PROCESS
6.1What is a Record?
6.2What is Records Management?
6.3Electronic Records Management Requirements
6.4Effective Electronic Records Management
6.5Creating a Document or File
6.6Naming Folders, Files and Documents
6.7Version Numbers
6.8Structuring Folders and Files
6.9Disclosure of Information about Staff
6.10Creating a Paper Document
6.11Filing Paper Documents
6.12Storage of Paper Records
6.13Electronic Document Imaging
6.14Retention Schedules
6.15E-mails
6.16Confidentiality and Security of Records
6.17Access to Records
6.18Sharing Records
7.TRAINING REQUIREMENTS
8.REFERENCES AND ASSOCIATED DOCUMENTATION
9.EQUALITY IMPACT STATEMENT
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
EQUALITY IMPACT SCREENING TOOL
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
All Trust staff, whether clinical or administrative, who create, receive and use records, have responsibility for records management. In particular all staff must ensure that they keep appropriate records of their work in the Trust and manage those records in keeping with this policy.
The purpose of this policy is to guide staff towards a systematic, consistent and planned approach to the management of non-clinical records
Trust non-clinical records are public records and may be disclosed under legal or professional obligations. Records belong to the Trust and not the individual who created them
Records can exist in any media including paper, electronic, photographs and images, and audio and visual recordings
Electronic records must be filed in appropriate shared network folders (‘p’ drive for personal information, ‘g’drive for Trust information) and should follow consistent naming conventions to ensure ease of retrieval. Folders should also be logically structured.
Paper records should follow similar naming conventions to electronic records and be filed in suitable,secure environmental conditions
Good ‘house keeping’ means records should only be held for the minimum necessary time. The Trust follows the record retention schedules as set out in the Records Management Code of Practice for Health and Social Care (2016)
Appraisal of administrative records should be carried out by a senior manager (clinical or non-clinical) who has an understanding of the operational area to which the record relates.
E-mails are valuable records and should be managed and filed accordingly (e.g. use network folders rather than relying on Outlook)
Records shared across the Trust should ideally be merged or effectively cross-referenced to ensure information can be ‘collected once and used many times’ and to avoid duplication.
Destruction of records should be undertaken appropriately for the media. Please follow the Trust’s Records Retention, disposal and destruction policy.
The destruction of any records must be clearly documented. Logs of records destroyed locally should be kept indefinitely by the responsible department. These logs should include the date of destruction and the type or name of the record destroyed.
If a record which is due for destruction is known to be the subject of a request for information, destruction should be delayed. It is a criminal offence under the Freedom of Information Act 2000 and the Data Protection Act 1998 to destroy or alter information that has been requested, in an attempt to avoid disclosure.
1.INTRODUCTION
All NHS records are public records under the terms of the Public Records Act 1958. Chief Executives and senior managers of all NHS organisations are personally accountable for records management within their organisation. The Secretary of State for Health and all NHS organisations have a duty under the Public Records Act 1958 to make arrangements for the safe keeping and eventual disposal of all types of their records. In addition, NHS organisations need robust records management procedures to meet the requirements set out under the Freedom of Information Act 2000 and the Information Governance Toolkit.
Records are a valuable resource because of the information they contain. High quality information underpins the delivery of high quality, evidence-based health care, and other service deliverables. Information is of greatest value when it is accurate, up to date and accessible when it is needed.
2.PURPOSE
To provide guidance to all staff within Portsmouth Hospitals NHS Trust (the Trust) to ensure there is a consistent, systematic and planned approach to the management of non-clinical records.
3.SCOPE
This policy covers all corporate / administrative records within the Trust. The ClinicalRecords Management Policy covers the management of health and clinical records. Both policies underpin the Information and Records Management Strategy. This policy will be a dynamic document, which will evolve as further NHS guidance becomes available, and should be read in conjunction with the Records Management Code of Practice for Health and Social Care 2016.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4.DEFINITIONS
G drive is the shared network storage area on the server
P drive is your personal area on the server
Recordis any recorded information created or received in the course of the Trust’s business and which needs to be retained in order to provide evidence of business activity, transaction or decision-making.
5.DUTIES AND RESPONSIBILITIES
Chief Executive:
The Chief Executive recognises that the records management function for the Trust is a specific corporate responsibility as it provides a managerial focus for records of all types, in all formats, throughout their lifecycle, from planning and creation through to ultimate disposal. The Chief Executive clearly supports the defined responsibilities and objectives, and supports adequate resources to achieve this.
Information Governance Manager:
The Information Governance (IG) Manager has lead responsibility for records management within the organisation.
Line Managers:
Managers with Clinical Service Centre (CSC) and/or speciality/ departmental responsibility for records management must work with the Information Governance Manager to ensure that there is compliance with this policy.
All Trust Staff:
All staff, whether clinical or administrative, must ensure that they are fully aware of their responsibilities in respect of record keeping and management. Under the Public Record Act 1958, all NHS employees have a degree of responsibility for any records that they create or use. Thus, any records created by an employee of the NHS are public records and may be subject to both legal and professional obligations.
6.PROCESS
6.1What is a 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. It includes therefore not only paper files series and digital records management systems but business and information systems and the contents of websites.’ (ISO 15489-1:2016)
A record is any recorded information created or received in the course of Trust business, which needs to be retained to provide evidence of a business activity, transaction or decision. Records can exist in any format or media, including paper, electronic, photographs and images, and audio and visual recordings.
Not all documents and files used in a business process will necessarily need to be captured into record keeping systems. Only those required to provide an adequate, accurate record of the work carried out or decisions made. The capture of relevant records into appropriate record keeping systems should be an integrated part of all Trust business processes.
The content of a record will primarily be determined by the purpose for which it is being created. Record keeping is a tool of professional practice and one, which should facilitate the care process. It is not separate from the process and it is not an optional extra to be fitted in.
6.2What is Records Management?
Records management is the activity of managing records throughout their lifecycle from creation, to disposal or permanent archiving, to destruction. It includes the capture, maintenance, retrieval, use, storage, review and transfer of records.
6.3Electronic Records Management Requirements
Electronic records within the Trust are to be clearly identified. They must be able to be preserved and stored for the required retention period. In order to ensure that the information constitutes a record the Trust is required and endeavours at all times to ensure that:
- The record is present – the information needed to reconstruct activities and transactions that have taken place is recorded and stored
- The record can be accessed – it is possible to locate and access the information
- The record can be interpreted – a context for the information can be established showing when, where, and who created it
- The record can be trusted – the information and its representation exactly matches that which was actually created and used, and its integrity and authenticity can be demonstrated beyond reasonable doubt
- The record can be maintained – the record can be deemed to be present and can be accessed, interpreted and trusted for as long as necessary and on transfer to other approved locations, systems and technologies
6.4Effective Electronic Records Management
Effective electronic records management supports:
- Efficient joint working and information exchange both internally and with other NHS organisations
- Evidence-based policy making by providing reliable and authentic information for the evaluation of past actions and decisions
- Administration of data protection principles and effective implementation of Freedom of Information and other information policy legislation, through good organisation of records
6.5Creating a Document or File
- Each department within the Trust shall keep adequate records to document its activities. When determining what records are to be kept, managers shall take into account public accountability, operational, legal and regulatory requirements.
- Records shall be complete and accurate enough to meet accountability, operational, legal and regulatory requirements.
- As far as possible, there shall be no unwarranted duplication of records.
- Records should be placed within designated record keeping systems that enable them to be accessed quickly and easily e.g. shared folders.
- Corporate record keeping systems shall classify and group records according to business function and activity, so that there is sufficient context to relate records to the business activities that they document.
- Wherever possible, records which have been created or received electronically shall be captured and stored in electronic record keeping systems i.e. not printed and stored in paper form.
- Electronic records shall be managed like any other record, in accordance with this policy.
When creating a new document (or any other file type), the use of templates and document marking (corporate logo) will help the Trustto create documents with a corporate look. The Trust logo should always be placed in the top right hand corner of the document and the recommended font is Arial size 11.
6.6Naming Folders, Files and Documents
Naming conventions are standard rules to be used for naming both documents and electronic folders and are used to make it easier to find documents. Corporate standards must be followed in the naming of record files and folders. It is unacceptable for any documents to leave the Trust without having either a logical file name or format for presentation that shows the Trust as being the owner of such documents. This corporate approach to the naming of electronic files will ensure that current and future staff will be able to create, update and search for files in a much easier manner.
Basic file naming practices:
- Give a unique name to each record, which is clear and simple
- Give a meaningful name which closely reflects the records contents
- Use standard terms for organisations, roles, projects, activities and other types of document (e.g. agenda / report / board paper)
- Express elements of the name in a structured and predictable order
- Locate the most specific information at the beginning of the name and the most general at the end
- Give a similarly structured and worded names to records which are linked (for example, an earlier and later version)
Electronic file names should not include excessive wording or inconsistent referencing formats.
- A file name description (normally the document title). Long words such as, management, organisation and department, should be shortened to ‘mgt’, ‘org’ and’ dept’. The file name must represent the content of the document. The document status is appropriate if the document is in preparation e.g. labelled ‘draft’.
- A version number in the format of e.g. v1
- A date reference may also be used to enable documents with the same titles but different dates to be distinguished.
- The file extension. This is normally allocated by the application i.e. ‘doc’ or ‘xls’. In general, if you cannot see a file extension, there is no need to add one as it will be assigned automatically by the application you are using.
Filenames should also replace a space with an underscore as this allows transfer to other computer systems keeping the file name in tact.
6.7Version Numbers
Where the record is likely to be replaced in the future by a new version, e.g. a policy, a version number should be included, both in the filename and also the document itself (usually via a template). The format to be used is v1, v2.
The key objective with version numbers is that the most current version is obvious and that there is an audit trail of previous versions.
6.8Structuring Folders and Files
A well thought out structure of folders (also known as directories or classification schemes) for filing documents is a key element to efficient electronic record keeping. There is a balance to strike between having many levels of folders and having a very ‘flat’ folder structure with everything under one major heading. Also, if the user needs to trawl through levels of folders to find the document they are likely to give up.
Folder titles should be clear and concise and adequately describe the contents.
Access to folders can be set up with varying degrees of permissions / controls, depending on the nature of the contents and who requires access.
The organisation should use a clear and logical filing structure that aids retrieval of records. Ideally, the filing structure should reflect the way in which paper corporate records are filed to ensure consistency. However, if it is not possible to do this, the names allocated to files and folders should allow intuitive filing. Filing of corporate records to local drives on PCs and laptops is not an acceptable practice.
6.9Disclosure of Information about Staff
There are generally two main areas where documents can be saved – either shared or personal folders. Both of which are located on the network.
The use of shared folders (G drive) should be adopted wherever possible to facilitate the sharing of Trust information and to improve access to the information during absences of individuals. Folder structure should allow logical access to data and should typically be set out around department, activities or projects, rather than the work of individuals. Examples of documents that should be stored in shared areas include; reports, training materials or staff rotas.
The IT helpdesk will be able to advise Trust staff on setting up shared folders and providing mechanisms to control access where required.
Private work-related documents, for example APDR preparation or Human Resource documents, should be stored in personal folders (P Drive), where they will only be accessible by the relevant individual. This area can also be used by staff to store a limited amount of personal items such as CVs or exam results.
(The data storage area on your computer)
6.10Creating a Paper Document
Records of business activity should be complete enough to:
- Facilitate an audit or examination of the business by anyone so authorised
- Protect the legal and other rights of the Trust, its clients and any other person affected by its actions
- Provide authenticity of the records so that the evidence derived from them is shown to be credible and authoritative
Paper records should be:
- Factual, consistent and accurate
- Written as soon as possible after an event has occurred, providing current information
- Written clearly and in such a way that the text cannot be erased
- Written in such a way that any alterations or additions are dated, timed and signed in such away that the original entry can still be read clearly
- Accurately dated, timed and signed with the signature printed alongside the first entry
- Not include abbreviations jargon, meaningless phrases, irrelevant speculation and offensive subjective statements
- Readable on any photocopies (Yellow highlighter does not photocopy)
- Written in black pen, not ink as this can run, and on white paper (other coloured pens and paper can be used providing the combination of pen and paper produces a legible and permanent record)
- Not include the use of correction fluid
6.11Filing Paper Documents
Where documents are kept as hard copy files, the filing structure and naming of the files should follow the same principles as described within the management of electronic files. All records should be arranged in a record-keeping system that will enable the Trust to obtain the maximum benefit from the quick and easy retrieval of information.