Patient Health Care Records Stra by ldd0229


									Patient Health Care Records Strategy
     (For the Record 1999/053)
                     TABLE of CONTENTS

1.    INTRODUCTION    ……………………………………………………                3

2.    AIMS & PRINCIPLES OF THE STRATEGY ………………………...      3

3.    BACKGROUND      …………………………………………………… 4

4.    CURRENT POSITION …………………………………………………                4



           6.1   STORAGE ……………………………………………… 6

           6.2   RETREIVAL OF PATIENT RECORDS ……………….     6

                 OF PATIENT RECORDS …………………………...         7

           6.4   RETENTION OF PATIENT RECORDS ….…………...   7

                 OF PATIENT RECORDS …………………………..          8


                 SECURITY OF PATIENTRECORDS…………………..      9

           6.8   KEY PERFORMANCE INDICATORS ………………... 11

7.    KEY ROLES & RESPONSIBILITIES ……………….……………….. 12

      STRATEGY …………………………………………………………….. 14

9.    PUBLICISING THE STRATEGY ……………………………………… 14



1. Introduction

This document presents a Strategy for the future management of all Patient Health
Care Records within the Organisation.

Although it is intended through this Strategy to bring together common processes for
good practice in records management across all patient areas of the Trust, it will be
necessary to adapt some of these to meet the local and specific needs of individual
departments. It is the aim of this paper to ensure that each of the following can be
achieved in all areas where patient records are stored:

- All Patient Records are properly controlled;
- All Patient Records are readily accessible and available for use;
- All Patient Records are properly archived or otherwise disposed of;

This paper is mainly concerned with those records which are held in paper format and
the management of X-ray Films. The Corporate Information Strategy will provide the
framework which will move the Trust towards the introduction of the Electronic
Patient Record (EPR).

2. Aims and Principles of the Strategy

In essence, this Strategy will provide a sound framework for systems, procedures and
responsibilities to ensure our working practices for patient record management are
consistently effective across all departments within the Trust.

The detail of the Strategy will cover the 12 main areas detailed below. Each
individual department with responsibility for holding patient records will create and
document their individual records policy covering each of the following.

·   Storage of Patient Records/Films
·   Retrieval of Patient Records/Films
·   Tracking and Controlling the movement of Patient Records/films within and
    outside of the Trust
·   Retention of Patient Records/Films
·   Alternatives of the permanent retention of Patient Records/Films
·   Disposal Methods of Patient Records/Films
·   Protecting the confidentiality and security of Patient Records/Films
·   Key Indicators to monitor effectiveness of the Strategy (Controls Assurance)
·   Key Roles and Responsibilities of Staff to ensure the strategy is fulfilled
·   Identification of resources to implement the Strategy successfully
·   Publicising and Training
·   Moving towards the Electronic Record

3. Background

HSC 1999/053 ‘For the Record’ was issued in 1999. The main purpose of this
circular was to move records management of all types, higher up the organisation’s
agenda by improving awareness of record type issues such as storage, accessibility
confidentialty and the safe destruction of records by linking the management of these
to overall business needs. Until this document was issued, there had been no great
emphasis placed on the quality of records management.

The Circular advised that all NHS Bodies with responsibility for the management of
records, should have a strategy agreed and implementation of it’s recommendations
including compliance and arrangements for monitoring its progress, to be well in hand
by April 2002.

In addition to HSC 1999/053, there are many other documents supporting the
importance of sound Record Management Practices in the NHS, namely:

- Caldicott Review of Patient Identifiable Information (HSC 1997/012)
- Information for Health - An Information Strategy for the Modern NHS from 1998 -
  2005 (HSC/1999/168)
- Data Protection Act - 1998
- The Protection and Use of Patient Information (HSC/96/58)
- A First Class Service - Quality in the New NHS
- Setting the Records Straight - A Study of Hospital Medical Records
- Controls Assurance in the NHS - Guidance for Directors
- CNST Standards - Clinical Negligence Standards for Trusts

Each of the above impact greatly on our record keeping procedures by ensuring that a
systematic and planned approach is taken across the organisation with regards to
confidentiality, security, retention and destruction of Patient Information.

Importantly, HSC 1999/053 also records that Chief Executives and Senior Managers
are personally accountable for the quality of records management and all line
managers and supervisors must ensure their staff are adequately trained and apply the
appropriate guidance.

4. Current Position

Within South Tees Hospitals NHS Trust the ‘Main Medical Records Service’ is
managed by the Trust Health Care Records Manager with Team Leaders based in
each of the hospitals. Multi-Specialty Patient Records are used in this area.

In addition to this however, there are many other health record type processes
including the storage of patient records being operated in ‘Non-Record’ departments
and for which the Trust Healthcare Records Manager has no responsibility. e.g.
Physiotherapy, Radiology and Pharmacy. Management of the record functions in
these areas forms one of many other responsibilities within people’s work.

Adherence to previous Department of Health guidance on record matters such as
storage, confidentiality and destruction of patient health records across the Trust is not

well documented and evidence about the standards being used is not generally

Within the Trust, the Health Care Records Committee exists to address issues such as
standardising the presentation of documentation within the casenotes and ensuring the
Health Care Records service meets the needs of clinicians. Directorates and divisions
who wish to alter documentation within the main ‘Multi-Specialty’ record should
notify this committee who will advise on standard requirements for new documents.
No documents for insertion into the patient record should be created without
notification to this committee.

5. Key Pressures On Areas Using Patient Records

There are varying but common pressures across each area holding patient
records/films and these can be summarised as:

·   There has been a lack of recognition within the Trust about the importance of
    good record keeping in order to reduce any risks of breaches of confidentiality,
    and ensure records are always available at the right time and place in order to treat

·   There is a severe lack of available storage space for all types of patient
    records/information within the Trust;

·   There is under-investment to successfully address storage of patient records/films
    in the Trust as a whole. Due to devolved responsibility for record keeping in each
    department, each area attempts to make its own arrangements which may or may
    not always comply with the safe storage and retrieval of patient information;

·   Devolved responsibilities for record keeping have resulted in duplication of
    information, effort, costs and services, particularly where the storage of
    information is concerned;

·   A patient record is incomplete due to the devolved nature of holding individual
    information about the patient in different departments. This may not be rectified
    until a full Electronic Patient Record is implemented.

·   The Trust is in the process of moving towards the introduction of the Electronic
    Patient Record. Until this Strategy has been agreed, then the storage and future
    management of Patient Records is unclear. The management and operation of
    existing Records needs to fit with the future EPR System(s).

·   In many areas, documented procedures about standards for record keeping are not
    available or need to be reviewed and made available to all staff who handle patient
    records. Controls Assurance Standards also need to be agreed for each area.

·   Training of staff to address issues such as confidentiality, security, retention and
    storage of patient information is vague, and monitoring of compliance does not
    generally take place;

·   Responsibilities and roles for staff to train, evaluate and monitor the success of
    our patient record keeping systems have not been clearly identified;
6. Implementing the Strategy - Proposals:

6.1 Storage of Patient Records/Information

Each department will document their departmental policy for the storage of both
active and non-active patient records. Practicalities required for storing these records
will depend on the type of record being stored, for example, diaries containing patient
information do not have to be accessible on a day to day basis. Any department
which will be considering the management of storing records will need to agree and
document the following standards within their policy:

-   Are the Patient Records being accessed daily
-   Appropriate lighting must be provided to assist staff to retrieve Patient
-   Lighting should conform to health and safety standards with regards to filing
    racking and shelving layouts
-   Racking and shelving will conform to height suitability, weight of the
    records/films and available working floor space
-   Equipment will be provided to assist staff to retrieve and transport notes/films i.e.
    trolleys, kik stools, computers
-   Pest control arrangements will be monitored in each filing area
-   Ventilation will be adequate to ensure dust problems are minimised
-   Notes will stored in adequate temperatures to ensure damage to hand-written
    information is minimal.
-   Records/films should be stored so that patient name, identification number etc.,
    are visible for fast and easy retrieval of documents.

6.2 Retrieval of Patient Record/Information

Where records/films are being filed both on-site and off-site, documented procedures
about how to retrieve these will be required and these should be publicised to all
appropriate staff with responsibility for this.

Where off-site storage is being used, then the arrangements to obtain patient
records/films both within normal office hours and outside of normal office hours must
be agreed with the third party. Where necessary, on-call arrangements must be
provided should active patient records/films be stored in off-site locations. Again,
these must be documented and be to the satisfaction of the Medical Director.

Continuous monitoring arrangements to assess the effectiveness of off-site storage
will be necessary.

6.3 Tracking and Controlling the Movement of Patient Records within and
    outside of the Trust

The timely availability of patient health records for the clinical attendance is
fundamental to patient care. Each department must ensure they have robust tracer
systems (manual or electronic) in place to be able to provide the record when the
patient is being treated.

For tracking the movement of the main ‘Multi-Specialty’ patient record, all staff
(mainly Health Records, Ward Clerks, Medical Secretaries and Staff based in
individual Directorates) who handle these, must use the computerised PAS tracking
system to update every location they may be sending patient records too. All of these
staff should have access to PAS and should be discouraged from keeping individual
booking out books which are not available for use by staff working elsewhere in the
Trust. Training on how to use the electronic tracking system can be provided by the
Health Care Records Department.

In those departments where other individual patient records are used for example
Physiotherapy/Occupational Therapy, then robust tracer systems for tracking their
records must be operated. These may be manual, for example, tracer cards may be
used when records are being provided to other users who are involved in the care of
the patient. Networked electronic tracer systems should however be encouraged.

The Radiology Department already operates a departmental electronic tracking
system for X-ray Films. This however is not extended for use by medical secretarial
staff outside of Radiology. Access to the Radiology system should be made available
to all staff who are handling X-ray films in the same way that the tracking system is
available for patient notes via CaMIS. Where ever possible, both the tracking systems
for patient notes and X-ray films should be combined so that staff do not have to log
into two separate systems i.e. CaMIS and Radiology. This will need to be a
development of any future PAS System.

The main responsibility of any tracking systems falls clearly to the person who is
removing or sending the patient notes/films to another location. All staff must be
sufficiently trained to take this responsibility for this action.

6.4 Retention of Patient Records

Information should only be kept for as long as it useful for the purpose. Each
department will append to their policy the retention periods for patient records/films
which they control. Once these periods have been reached, then destruction using the
methods identified in 6.6. below can take place.

6.5 Alternatives for Permanent Retention of Patient Records/Information

Policies already exist for the permanent retention of patient records onto microfilm
but these solely apply to the main ‘Multi-Specialty’ type records as follows:

- Adult records (live and deceased) can be microfilmed two years after last
- Children and Obstetric records can be microfilmed five years after last
- Radiology destroy X-Ray films 8 years after last attendance

Although the above policies exist and no records are placed on microfilm before the
above time criteria are achieved, it is not possible to strictly manage the system in
accordance with that criteria. The result being that notes exist outside of these
timescales and this situation largely contributes to our storage problems.

It is logical to continue with the policy to microfilm the Main Multi-Specialty
Records in preparation for movement into Single Site and then as the Trust develops
its Strategy to move towards the Electronic Patient Record, other alternatives to store
paper records onto alternative media such as digital imaging can be explored.

If other Non-Record departments feel they should pursue alternatives to storing their
patient records in the short-term, then apart from using off-site storage facilities, any
move towards transferring this to electronic media at this stage must be aligned with
the future Corporate Strategy for the Electronic Patient Record.

6.6 Disposal Methods for Patient Records/Information

Any piece of documentation containing details which can identify an individual must
be safely destroyed once the period for retention has been reached.

Each department must ensure their staff are aware of their responsibilities to ensure
staff destroy patient information safely. Destruction of patient information will
include incineration or shredding. Patient identifiable information must not be placed
in waste paper bins. All patient identifiable information should be placed in black
plastic bags to be disposed of either by incineration or shredding.

Some departments may already have their own             shredding machine facilities.
Alternatively, the Trust already contracts this type    of work out to a recognised
shredding company and each department must raise        the appropriate official orders
required for the company to come on site to collect     and destroy the data for each

X-Ray films are destroyed by incineration with contracted 3rd party companies.

6.7 Protecting the Confidentiality and Security of Patient Records

The Data Protection Act defines a patient health record as any recorded data relating
to the physical or mental health of an individual who can be identified from that
information and which has been made by or behalf of, a health professional in
connection with the care of that individual. (This may be electronic data as well as
manual data). Procedures are detailed below to ensure this information is protected at
all times:-

6.7.1 Any member of staff who handles or stores patient information has a personal
common law duty of confidence to patients and the Trust. This must form part of the
employee’s contract of employment as well as being reiterated in any induction
training for new employees. Each employee must understand their responsibilities for
handling and safeguarding all patient information whilst it is in their possession and
each department holding patient records must comply with the following basic

-   All computerised information about patients should be protected by password
    entry which should be individual to each user;

-   Offices/departments holding patient records must be locked when vacant.
    Where entry by authorised users is required to obtain patient records
    outside of normal working hours, documented procedures for each area
    should be agreed with the appropriate line manager. Security Staff can
    provide access to locked offices when required. Each department manager
    will specify the arrangements for obtaining patient records out of hours and
    the opening and closing times for each area under their control.

-   If records are being removed from any office, the person removing these must
    leave details to notify the main office user about what has been taken, who has
    taken it, and for what purpose;

-   Any person removing the records must ensure the appropriate tracking
    system for that record is updated with the new location. In the case of Multi-
    Specialty records, this will be the computerised PAS tracking system;

-   Each main records department must operate a suitable intercom/key pad
    access entry system if practical, during the normal working day for visitors
    to report too. Where this is not practical, then records staff must be
    available and be aware of who is entering their department to offer assistance
    when required. Notes must not be removed from any of the main libraries
    without being tracked out on the appropriate tracking system. Authorised
    staff taking notes must ensure any patient records being taken are tracked
    out before leaving the Health Records department.

-   Each main records and X-ray department will work towards operating a ‘Closed
    Library’ concept prior to Single Site if practical. This is to reduce the numbers of
    Non-Records staff who are currently able to remove notes from the filing system.
    This will require additional staff resource to deal with the volume of requests
    which would be made by Non-Records staff to be provided with patient

With Single Site development, the Trust will implement a closed library in the main
Health Care Record area and will explore the use of smart cards for use by authorised
staff to gain entry, out of hours, to filing areas and individual offices/departments
where patient notes or films are being stored. This may limit the numbers of staff
who have access without authorisation to these areas or at least will record who has
gained entry over each 24-hour period.

6.7.2 Requests for patient information may be received by telephone. All staff must
establish whom they are talking to at all times and the following guidelines should be

-   The member of staff who takes the call should ensure that all requests for
    patient records/information from outside agencies or organisations are put in
    writing by letter or fax and these must be on the other agencies/organisation’s
    letter headed paper. With each of these requests patient consent must be provided
    except in the cases where emergency treatment is being provided.

-   If a request for information is received from a Health Professional and there
    is any doubt as to the identity of that person, the member of staff should
    agree to ring back the caller using the published telephone number for the
    NHS organisation. If any further doubt exists, then the immediate Line
    Manager must be informed so that decisive action can then be taken.

-   Original patient notes will not be sent outside of our Trust except in the case of
    emergency care being provided. In all other instances, all notes must be
    photocopied and it is the responsibility of the person receiving the call to
    ensure this is followed.

6.7.3 Records being sent outside of the Trust must be securely packaged and fully
addressed with an ‘acknowledgement of receipt’ system being operated:

The only reason patient records should be sent outside of the Trust will be to ensure
treatment of the patient can be continued. Such examples of this would be if the
patient is admitted as an emergency to another Hospital. In these instances, records
can be sent without obtaining the permission of the Clinician within this Trust.

Should any other requests be received to borrow patient records from outside of the
Trust (e.g. elective admission or a future outpatient appointments, private treatment
etc.,) then photocopies and permission of the Clinician must be obtained. Original
records should never be despatched except where emergency care is being provided.

When records (actual or photocopies) are being sent to another location outside of the
Trust, then the person sending them will be responsible for ensuring these are securely
packaged to avoid any documents being destroyed, lost or damaged in the external
postal system. Padded Envelopes should be used to protect the patient‘s
documentation. Records/copies can be sent in the first class postal system however,
an acknowledgement of receipt must be enclosed for completion by the receiver who
should return this to the sender. The sender will be responsible for ensuring this
system is operated and will store the receipts for audit purposes within their own

Where information is being faxed to authorised staff both within and outside of the
Trust, this must be followed up with a phone call to the receiver to ensure the
information has been received correctly.

6.8 Key Performance Indicators (Controls Assurance)

Within the Controls Assurance Standard for Records Management, Criterion 9 states:

    ‘Key indicators capable of showing improvements in records management and/
     or providing early warnings of risk, are used at all levels of the Organisation,
     including the board, and the efficacy and usefulness of the indicators will be
     reviewed regularly’

The Key indicators to measure the effectiveness of our Patient Health Care Record
Procedures are:

·   Number of records/films which were not available at the time the patient was
    being treated. This should include a record of follow-up action to investigate each
    incident where Patient Records/films have not been available
·   Number of external complaints received within each service about poor quality of
    information contained within a patient record. This information can be provided
    via the Legal and Risk department for the Trust directly to individual departments
    and will include details about the structure of the record, legibility, accuracy
    and completeness of the information being stored.
·   Number of incidents about breaches of confidentiality by staff for each
·   Number of Health and Safety incidents reported where staff have been injured as a
    result of using or retrieving patient records. This will identify whether Health and
    Safety Standards for storage of patient information has been applied
·   Training Records exist for all staff to ensure they have been made aware of each
    departmental policy regarding the management of patient records within their area
    of work

Each patient record area must create and use systems which allow the effective
monitoring of the above indicators. Two audits will be performed each year by the
local Record Managers within each department to review the effectiveness of security
systems for storing and managing patient records/information.

7. Key Roles and Responsibilities to Implement the Strategy Successfully

The Management Group

Agreement to support the recommendations made in section 6 will be required by the
Management Group and Trust Board if we are to implement this Strategy successfully

Director of Information

Overall, through delegated responsibility to the Local Record Managers, the Director
of Information has corporate responsibility for the management of Clinical and Non-
Clinical Records Management. Their responsibilities will include:

·   Moving records management higher up the Organisation’s agenda via the
    Management Board
·   Improving awareness of good record keeping practices
·   Ensuring records are kept confidential and the link is maintained with the
    Caldicott Guardian
·   Ensuring there is link between the strategies for manual and future computerised

Local Record Managers

To successfully implement the strategy within the Trust, the following Local Record
Managers have been identified to:

·   Organise, assist and document the effectiveness of Records Management within
    their area using the indicators identified in 6.7 above
·   Offer guidance on Record Management issues to staff within their area of
·   Co-ordinate, publicise and monitor implementation of the strategy and Record
    Policies for their own area of responsibility.
·   Provide input to the Records Management agenda via the Health Records

Local Records Managers have been identified below:

Service:                                   Responsibility:
Main Patient Health Care Records           Trust Health Care Records Manager
Physiotherapy/Occupational Therapy         Director of Physiotherapy
Dietetics                                  Trust Dietetic Manager
Pharmacy                                   Office Manager – Pharmacy Department
Radiology                                  Office Supervisor – Radiology Department
Pathology                                  Office Manager – Pathology Department
Women & Children                           Information Manager – Women & Children

Line Managers

Departmental Line Managers must ensure their staff are adequately trained and apply
the appropriate guidelines as detailed below:

·   Confidentiality of patient records/information
·   Security and release of patient records/information
·   Retention and destruction of patient records/information
·   Tracking and controlling of movement of patient records/information around the
    Trust and when being sent out of the Trust
·   Locate, store and move patient records/information correctly

The Employee

In practice, any records which are created within the NHS are public records and as
such, all NHS employees who record, handle, store or who may otherwise come
across patient information have a personal ‘common law duty of confidence’ to
maintain to our patients and to his or her employer. This duty of confidence continues
even after the death of the patient and after an employee has left the NHS. Breaches
of confidentiality will be dealt with via the disciplinary procedure and could result in
employment dismissal.. Every employee handling patient information must ensure:

·   It is stored securely whilst in their possession
·   Patient records/information should not be released to outside agencies or
    organisations without the appropriate safeguards being taken. i.e. requests in
    writing, identity of caller being checked, patient consent must be provided by the
    requester except in cases of emergency treatment and photocopies being provided
    except in the case of emergency treatment. Consent of the Clinician or
    appropriate Health Care Professional who last treated the patient is required to
    release the information again except in the case of emergency treatment.
·   Record locations are accurately updated to assist all users to locate the records
·   Records are safely packaged and correctly addressed when being sent to any other
·   Records are destroyed using the Trust’s or departmental destruction procedures
    i.e. departmental shredding if equipment is available or making arrangements
    through their line manager for the appropriate shredding company to come on site
    to collect and destroy this information.

8. Identification of Resources to Implement the Strategy

Once this Strategy has been approved by the Management Group and Trust Board, it
is important to ensure those staff identified as Local Record Managers are offered the
appropriate support to carry out their responsibilities. Any issues identified which
puts patient record procedures at risk, and which is beyond the control of the service
to rectify locally, should be notified to the Trust’s Health Records Committee in the
first instance for advice and be supported by the appropriate business case identifying
resources (staffing or environmental) which may be required. Management Group
and Trust Board will then need to consider how the issue can be addressed to remove
any risk to the patient record.

9.   Publicising and Training

It is envisaged that with the establishment of a Local Manager’s Network, publicising
of the Strategy will be undertaken by each Local Records Manager who will ensure
all staff working to them are made aware and fully understand the requirements of
their own departmental policy for the management of patient records within their area.

It will be the responsibility of the Local Records Manager with the assistance of each
of their Line Managers to ensure all staff reporting to them understand and are
adequately trained to carry out procedures that ensure patient records/information are
stored confidentially and securely and are disposed of in the correct manner.

10. Moving towards the Electronic Record

The Corporate IS/IT Strategy presents the future direction for the Trust to move
forward on the development of electronic clinical information systems which will
meet the Department of Health’s targets on implementation of Electronic Patient
Records by 2005.

Whilst implementation of the IS/IT Strategy will not remove the need to maintain
paper records, it will facilitate increased electronic storage of patient information. As
the electronic systems are being developed, the Health Care Records service and
functions will inevitably change to support that project.


To top