Clinical Records Management Policy
Date of Implementation: / December 2011Date of Next Review: / December 2014
Version No: / 1.10
Approved at: / IG Committee
Originator: / Information Governance Manager
Lead Director: / Senior Information Risk Owner (SIRO)
Contents Page
1 Introduction 4
2 Definitions 4
3 Scope 4
4 Roles and Responsibilities 5
4.1 Chief Executive 5
4.2 Caldicott Guardian 5
4.3 Medical Director 5
4.4 Medical Records Committee 5
4.5 Head of Performance & Planning 65
4.6 Information Governance Manager / Information Governance Committee 65
4.7 Medical Records Manager 65
4.8 Executive/Clinical Directors, General Managers 6
4.9 Service Managers, Assistant Service Managers and Departmental Heads 6
4.10 All Staff 6
5 Legal Obligations 6
5.1 Data Protection Act (DPA) 1998 6
5.2 NHS Confidentiality Code of Practice April 2007 76
5.3 The Caldicott Principles 7
6 Professional Obligations/Standards 7
6.1 Professional Obligations 7
6.2 NHSLA Risk Management Standards for Acute Trusts 87
6.3 NHS Number 8
7 Unified Medical Record 98
7.1 Trust Medical Record 98
7.2 Emergency Department Record 9
7.3 Genito Urinary Medicine (GUM) 109
7.4 Maternity Record 109
7.5 Nursing Records 1110
7.6 Pathology Records 1110
7.7 Private Patients 1110
7.8 Radiology Records 1110
7.9 Research Records 1211
7.10 Therapies – Occupational Therapy 1211
7.11 Therapies - Physiotherapy Records 1211
7.12 Allied Health Professional Records (AHP) 1311
8 Record Information Quality Assurance 1311
9 Record Creation 1312
9.1 Clinical Record Creation 1312
9.2 Creation of Temporary Medical Records 1412
10 Record Management 1413
10.1 Allergy Recording 1413
10.2 Use of stickers on the front of Trust Medical Records 1513
10.3 Special Needs 1513
10.4 Copying Letters to Patients 1513
10.5 Advance Healthcare Decisions 1513
10.6 Medical Records Volumes 1514
10.7 Maintenance of Medical Records 1614
11 Records Storage 1614
11.1 Clinical Record Storage 1614
11.2 Medical Records Library 1614
11.3 Storage of Medical Record outside of Medical Record Library 1614
11.4 Storage of Medical Records on the wards 1715
11.5 Trust Off-site Storage 1715
12 Records Tracking / Transportation 1715
12.1 Tracking Medical Records 1715
12.2 Transportation of Clinical Records within the Frimley Park Site 1815
12.3 Transportation of Clinical Records off site 1816
12.4 Removal of a clinical record from the Trust Premises 1916
13 Record Disclosure 1916
13.1 Internal Requests for Medical Records Required for Clinical Care 1916
13.2 Release of Medical Records to Other NHS Providers 1916
13.3 Release of Medical Records to a Third Party 2017
14 Records Retention 2017
14.1 Clinical Record Retention 2017
14.2 Microfilmed Records 2118
14.3 Scanned Records 2118
15 Records Destruction 2118
15.1 Clinical Record Destruction 2118
16 Record Disposal 2218
16.1 Clinical Record Disposal 2218
17 Monitoring of Policy 2219
17.1 Medical Records Availability 2219
18 Breaches of policy 2219
19 Training 2219
20 Review 2320
21 Equality Impact Assessment 2320
Appendix 1 - Clinical Records Retention Schedule 2320
Clinical Records Retention Schedule 2521
Pharmacy Retention Schedule 2824
X-Ray Retention Schedule 2824
Appendix 2 – Trust Clinical Electronic Systems 2925
1 Introduction
1.1.1 Records Management is the process by which an organisation manages all the aspects of records whether internally or externally generated and in any format or media type, from their creation, all the way through their lifecycle to their eventual disposal.
1.1.2 The Records Management: NHS Code of Practice has been published by the Department of Health as a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice.
1.1.3 The Trust’s records are its clinical memory, providing evidence of actions and decisions relating to patient care and representing a vital asset to support the treatment of patients. Clinical records support and protect the interests of the Trust and the rights of patients, staff and members of the public.
1.1.4 This policy determines the standards which must be followed when handling and dealing with any Trust Clinical record.
1.1.5 This Clinical Records policy should be read in conjunction with the Trust’s Records Management Strategy and the Trust’s Non-Clinical Records Policy.
2 Definitions
2.1.1 A Record is defined as anything which contains information (in any medium) that has been created or gathered as a result of any aspect of the work of NHS employees, including (but not limited to) bank, agency and locum staff; students; voluntary staff and trainees on temporary placements.
2.1.2 A Clinical Record is defined as ‘any record which consists of information relating to the physical or mental health or condition of an individual and has been made by or on behalf of a health professional in connection with the care of that individual’.
3 Scope
3.1.1 This policy applies to all Trust Clinical records, both manual and computerised including joint health and social care records.
3.1.2 The main principles of this policy are:
· it relates to all clinical records held in any format by the Trust;
· it applies to information in paper and other physical forms, e.g. electronic, microfilm, negatives, photographs, audio or video recordings and other assets;
· it relates to the 5 distinct phases in the life of information; creation, retention, maintenance, use and disposal;
· to set out the Trust’s commitment to create, keep and manage clinical records, including electronic records which document the treatment provided to patients.
· to define a structure for the Trust to ensure adequate clinical records are maintained, managed and controlled and comply with legal, operational and information needs.
3.1.3 Records can be created by anyone working within or on behalf of the Trust. This includes, but is not limited to, employees, agents, contractors and volunteers in any capacity.
3.1.4 This policy sets out a framework within which the staff responsible for managing the Trust’s clinical records can develop specific policies and procedures to ensure that all clinical records are managed and controlled effectively and at best value commensurate with legal, operational and information needs.
4 Roles and Responsibilities
4.1 Chief Executive
4.1.1 The Chief Executive has overall responsibility for records management in the Trust. As accountable officer he is responsible for the management of the Trust and for ensuring appropriate mechanisms are in place to support service delivery and continuity. Records management is key to this as it will ensure appropriate, accurate information is available as required.
4.1.2 The Chief Executive has a particular responsibility for ensuring that the Trust corporately meets its legal responsibilities and for the adoption of internal and external governance requirements.
4.2 Caldicott Guardian
4.2.1 The Trust’s Caldicott Guardian has a particular responsibility for reflecting patients’ interests regarding the use of patient identifiable information. He is responsible for ensuring patient identifiable information is shared in an appropriate and secure manner.
4.3 Medical Director
4.3.1 The Medical Director has Executive responsibility for the management of Trust Clinical Records.
4.4 Medical Records Committee
4.4.1 Day to day management of the Trust’s medical records is undertaken by the Medical Records committee, which is chaired by a senior clinician.
4.5 Head of Performance & Planning
4.5.1 The Head of Performance & Planning has the responsibility for the day-to-day management of the Trust’s Medical Records.
4.6 Information Governance Manager / Information Governance Committee
4.6.1 The Trust’s Information Governance Manager/Committee is responsible for ensuring this policy is implemented through the implementation of a Records Management Strategy, and that the records management systems and processes are developed, co-ordinated and monitored.
4.7 Medical Records Manager
4.7.1 The Medical Records Manager is responsible for the overall development and maintenance of the Trust’s medical records management policies and their implementation throughout the Trust, in particular for drawing up guidance for good medical records management practice and promoting compliance with this policy in such a way as to ensure the easy, appropriate and timely retrieval of patient information.
4.8 Executive/Clinical Directors, General Managers
4.8.1 Executive/Clinical Directors and General Managers are responsible for ensuring that departmental policies and procedures relating to the management of their clinical records comply with this Policy and that risks associated with their clinical record usage are managed and controlled.
4.9 Service Managers, Assistant Service Managers and Departmental Heads
4.9.1 Service Managers, Assistant Service Managers and Departmental Heads are responsible for ensuring that staff within their Department receive training on this policy and their own departmental clinical records procedures to ensure clinical records management and associated risks are controlled.
4.10 All Staff
4.10.1 All Trust staff, whether clinical or administrative, who create, receive and use clinical records have records management responsibilities. In particular, all staff must ensure that they maintain accurate and available clinical records for patients and ensure those records are managed in line with this policy and with any guidance subsequently produced.
5 Legal Obligations
5.1 Data Protection Act (DPA) 1998
5.1.1 The Data Protection Act regulates the processing of personal data, held manually and on computer. It applies to all personal information; not just health records. Personal data is defined as data relating to a living individual that enables him/her to be identified either from that data alone or in conjunction with other information in the data controller’s possession. It therefore includes such items as an individual’s name, address, age, race, religion, gender and physical, mental or sexual health.
5.1.2 The Act contains 3 key strands:
· Notification by a data controller to the Information Commissioner
· Compliance with the 8 data protection principles
· Observing the rights of data subjects
5.1.3 Clinical Records management staff have a key role to play in ensuring that records can be located, retrieved and supplied in a timely manner.
5.2 NHS Confidentiality Code of Practice April 2007
5.2.1 This Code of Practice provides guidance to the NHS and related organisations on the handling of confidential patient information across the NHS. Patient information is held under legal and ethical obligations of confidentiality. Information provided in confidence must not be used or disclosed in a form that might identify a patient without his or her consent.
5.2.2 The Confidentiality Code of Practice describes a Confidentiality Model which has 4 key requirements:
· Protect – look after the patient’s information
· Inform – ensure patients are aware of how their information is used
· Provide Choice – allow patients to decide whether their information can be disclosed or used in particular ways
· Improve – always look for better ways to protect, inform and provide Choice
5.3 The Caldicott Principles
5.3.1 The 6 Caldicott Principles must be observed when disclosing confidential patient information to any other person either working for the Trust or for another healthcare provider:
· Justify the purpose
· Do not use patient identifiable information unless absolutely necessary
· Use the minimum necessary patient identifiable information
· Access to patient identifiable information must be on a strict need to know basis
· Everyone must be aware of their responsibilities
· Everyone must understand and comply with the law.
6 Professional Obligations/Standards
6.1 Professional Obligations
6.1.1 All Trust Clinical Records must be a legible record which:
· Enables the patient to receive effective continuing care
· Enables the healthcare team to communicate effectively
· Enables the patient to be identified without risk of error
· Facilitates the collection of data for research, education and audit
· Can be used in legal proceedings
6.1.2 The Trust has comprehensive systems in place for the access, storage, retrieval, usage, retention and destruction of all Trust Clinical records.
6.1.3 Clinical Record keeping standards are monitored through the clinical audit process.
6.2 NHSLA Risk Management Standards for Acute Trusts
6.2.1 This policy must ensure compliance with the NHSLA Risk Management Standards for Acute Trusts.
6.2.2 The original standards of the Clinical Negligence Scheme for Trusts continue to be applied to clinical records management, namely:
· There is a unified medical record which all specialties use
· Records are bound and stored so that loss of documents and traces are minimised for inpatients and outpatients
· There are clear instructions in the medical record regarding the filing of documents
· Operation notes, care pathways and other key procedures are readily identifiable
· Machine produced medical records are securely stored and use a method that minimises deterioration to ensure availability during the entire retention period
· Storage arrangements allow retrieval on a 24 hour/7 day basis
· There is continuous multi-professional clinical audit of record keeping standards, including high risk services
· There is a mechanism for retaining certain records which must not be destroyed
· The medical record contains a designated place for the recording of hypersensitivity reactions and other information (e.g. Special Needs) relevant to all healthcare professionals
· A&E records are contained within the main record for patients who are subsequently admitted
· There is a system for ensuring that the GP is sent a copy of the A&E record
· Nursing, medical and other records (e.g. physiotherapy notes, obstetric notes), are filed together or referenced when the patient is discharged
· There is a system for measuring efficiency in the recovery of records for inpatients and outpatients
· An author of an entry in a medical record is clearly and easily identifiable
6.3 NHS Number
6.3.1 The NHS number is the unique identifier for all patient records and is a component of NHS CFH. Use of the NHS number will allow linkage of patient records across systems and organisations. It is envisaged that record linkage will improve effectiveness and efficiency of clinical care to patients and support the concept of a lifelong record. The Trust is required to ensure all clinical systems contain the NHS number and each system fully adopts the NHS Number in order to be compliant with the National NHS Number Information Standard.