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					Health Records Management

Information Governance Policy Team
NHS Connecting for Health
Key Learning Points
 1. Responsibilities for health records
 2. Record Lifecycle Management
 3. Auditing current health records practices & procedures
 4. Undertaking an records inventory survey of existing
    health records systems
 5. Drafting/maintaining the organisation’s health records
    management policy
 6. Drafting/maintaining the organisation’s health records
    management strategy & associated action plan
 7. Raising awareness of the importance of health records
    management throughout your organisation
Responsibilities 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

There are therefore INDIVIDUAL, STATUTORY
& MANAGERIAL responsibilities for all NHS
records, including health records
 Record Lifecycle Management

               Close Record

Create   Use                   Retention   Appraisal   Disposal

Be aware                      Monitor             Control
Information Requests

   NHS records may be subject to
       information requests
Health Records Policies &

 Procedure
 Policy and Procedure manual
  Key management tool
  Basis for specific training
Auditing Health Records Policies &
Procedures – The Audit Cycle

The audit cycle
Undertaking a Records Inventory

 Guidance has been produced to help those
  organisations that have not yet started to establish a
  records inventory or are still in the in the early stages
  of completing one
 The guidance & a records inventory survey form are
  available in the records management roadmap and
  they are summarised in the following slides.
 Practical Steps

 A health records                 Step   8 Databases storing research Health
  inventory is one                 3        information, etc           Records
                                          7 Electronic records
  component of the                          replicating PAS e.g.
  complete records                          waiting and clinic lists
  inventory                               6 Standalone clinical systems

 It can be                 Step   5 Clinical systems (PAS fed)
  completed in 3            2
                                   4 Patient Administration Systems
  steps                              (PAS)
                     Step   3 Scanned, microfilm records
Insert 3 step               2 Admission, day, ward books, diaries,
                              index cards
                            1 Paper health records
Distributing & Completing the

 Distributing & Completing the Inventory Forms

 Aggregating the Inventory Form
Benefits of a Health Records
Improves compliance with:
 Records Management: NHS Code of Practice
 IG Toolkit requirements
 NHS Litigation Authority’s risk management
 Standards for Better Health
 Professional standards
Benefits of a Health Records
Informs the Board’s Assurance Framework
 Identifies managers and ‘owners’
 Identifies sharing arrangements
 Identifies the format in which records are
 Allows mapping to retention schedules
 Ensures appropriate training
 Identifies storage conditions
 Identifies security arrangements
Keeping the Inventory Up to Date

 The inventory needs to be accurate & kept up
  to date
 Health records manager must keep the health
  records inventory up to date
 Records management lead has responsibility
  for keeping the corporate inventory up to date
Health Records Management Policy
A health records management policy applies to all
  types of health record regardless of the media
  on which they are held
Its sets out a framework within which to develop
   specific policies and practices to ensure that
   health records are managed and controlled
Model documentation is available in the records
 management roadmap
Aims of a Health Record
Management Policy
To ensure that health records:
     are available when needed
     can be accessed
     can be interpreted
     can be trusted
     can be maintained through time
     are secure
     are retained and disposed of appropriately
     staff are appropriately trained
Drafting and maintaining a Health
Records Management Strategy
 The health records management strategy applies to all
  health records of all types regardless of the media on
  which they are held;
 It should be an integral part of the organisation’s wider
  records management strategy and be compliant with
  the organisation’s records management policy. If the
  strategy and policy have not yet been written, model
  documentation is available in the records
  management roadmap
Aims of the Records Management
   Responsibility and accountability
   Record quality
   Management
   Security
   Access
   Audit
   Training
Why do we need a Health Records
Management Strategy?
 To provide a robust baseline from which to move forward;
 To identify how the management of health records is currently
 To identify what health records the organisation generates and
  how they are archived and stored;
 To enable the organisation to meet existing and future demands
  for health records management;
 To ensure that the organisation meets it’s legal and statutory
  obligations in respect of health records;
 To help NHS organisations to improve the standard of health
  records management and to raise the profile of the service within
  the organisation.
Tools to inform the strategy
   Records inventory survey
   Audit of HRM policies & procedures
   Assessment of environmental conditions
   Access controls for storage areas
   Assessment of tracing/tracking systems
   Mapping of records to retention schedule
   Review retention & destruction procedures
   Training provision
The Planning Cycle

        3. How are we going to
               get there
          & how will we know
                                                     1. Where are we now?
            what progress
                                                      (Position Statement)
            We are making?
            (Action Points
         & Monitoring Criteria)

                             2. Where do we want to be?
                                 (Goals & Objectives)
Where are we now?#1
(Position Statement)
 Results of baseline audit - list the types and
  numbers of records and locations where they
  are stored and who is responsible for
  managing them;
 Describe environmental conditions;
 Document security & access arrangements to
  storage areas;
Where are we now?#2
(Position Statement)
 Document retention periods for all types of
  records in line with the current retention
  schedule and indicate the organisation’s
  compliance status;
 List existing policies & procedures including
  retention, weeding, archiving & destruction.
Developing the Action Plan
(Identifying Goals & Objectives)
 Is there a designated manager responsible for each
  collection of records?
 Are you storing more records than necessary?
 Is there sufficient storage space for them?
 Are environmental conditions appropriate & safe?
 Do you need additional storage?
 Do you need to look at archiving solutions?
 Are disposal & destruction arrangements appropriate?
Where do we want to be?
(Goals & Objectives)
 Goals & objectives should be SMART
Developing the Action Plan#1
(How Are We Going To Get There?)
Action Points
• Identify tasks related to each of the goals and
   • Specify timescales
   • Specify resources required
   • Specify responsibility for action(s)
• Quantify resources required & produce a
  business case to secure additional resources if
Developing the Action Plan
(How Will We Know
What Progress We Are Making?)
Monitoring Criteria

 Determine monitoring criteria & timescales:-
    Specify how progress will be monitored
     and when
    Specify how progress will be reported
 Schedule monitoring meetings aligned with the
  timescales & milestones in the strategic plan
The Health Records Management
Strategy – Making it Happen
The strategy should:-
 Contain a realistic action plan with achievable
  milestones and timescales for implementation;
 Identify resources required to achieve the
 Identify possible risks, which may jeopardise
  the plan;
 Have regular reviews of progress built in to it.
Keeping The Strategy Under Review

 Review the strategy annually
 Maintain close links with the IM&T & corporate
  records management strategies
 Maintain close links with the IGT assessment
Raising awareness of Health Records
Management – Why?
 To ensure that everyone knows who has the
  lead role for records management in the
 To ensure that all members of staff understand
  their personal responsibilities in respect of
  health records management
 To ensure that issues and progress on health
  records management are routinely fed back to
  the Board
  Further Guidance and
  useful links
Records Management NHS         DH: Records Management
Code of Practice               NHS Code of Practice
Information Governance         www.igt.connectingforhealth.n
Records Management             www.connectingforhealth.nhs.
Roadmap                        uk/infogov/records
NHS IG Policy Team website     www.connectingforhealth.nhs.
(Find out more about IG)       uk/infogov
Department of Health website