Records Retention and Disposal Policy by malj

VIEWS: 116 PAGES: 8

									                      Records Retention and Disposal Policy




Reference Number                                1.20

Version                                         2

Name of responsible (ratifying) committee       Information Governance Steering Group

Date ratified                                   07 December 2009

Document Manager (job title)                    Information Governance Manager

Date issued                                     22.12.2009

Review date                                     December 2011

Electronic location                             Corporate Policies
                                                Clinical Records Management Policy, Non-Clinical
Related Procedural Documents                    Records Management Policy, Records Management
                                                Strategy, Freedom of Information Policy
                                                Freedom Information Governance Records retention,
                                                records disposal, records management control of
                                                corporate information archive archiving keeping patient
                                                records Information management; Data Protection Act
Key Words (to aid with searching)
                                                1984; Data Protection Act 1998; Data protection;
                                                Freedom of Information Act 2000; Health Records;
                                                Non-Clinical Records; Destruction; Confidentiality;
                                                Disposal procedures


Records Retention and Disposal Policy. Issue 2. 22.12.2009       (Review date: December 2011)
                                                                                   Page 1 of 8
CONTENTS

      QUCK REFERENCE GUIDE…………………………………………………………………………...3
1.   INTRODUCTION.......................................................................................................................... 3
2.   PURPOSE ................................................................................................................................... 4
3.   SCOPE ........................................................................................................................................ 4
4.   DEFINITIONS .............................................................................................................................. 4
5.   DUTIES AND RESPONSIBILITIES .............................................................................................. 4
6.   PROCESS ................................................................................................................................... 5
      6.1. SCHEDULES ................................................................................................................... 5
      6.2. APPRAISAL OF RECORDS ............................................................................................ 5
      6.3. RECORD DISPOSAL ...................................................................................................... 5
      6.4. DESTRUCTION OF RECORDS ...................................................................................... 6
7.   TRAINING REQUIREMENTS ...................................................................................................... 6
8.   REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 6
9.   MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
     DOCUMENTS .............................................................................................................................. 7

       Appendix 1: Record Destruction Flowchart




Records Retention and Disposal Policy. Issue 2. 22.12.2009                                  (Review date: December 2011)
                                                                                                              Page 2 of 8
QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.

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.

   1. Records refer to all corporate/business records (including emails and text messages) and
      health records (e.g. patient health records, theatre and A&E registers, x-rays, audio and video
      tapes).

   2. The Trust must take steps to prevent the ad hoc disposal of records and ensure that final
      disposal of records is in accordance with legislation and key guidance.

   3. All Trust staff, whether clinical or administrative, who create, receive and use records have
      records management responsibilities. 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.

   4. The Trust follows the record retention schedules as set out in the Records Management NHS
      Code of Practice (DoH 2006) Part 2.

   5. 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.

   6. Appraisal of health records will be undertaken by the Health Records Operational Manager
      (or person with delegated responsibility) with appropriate clinical and management support as
      required. The management of departmentally held records, i.e. GU Medicine, is the
      responsibility of the departmental managers

   7. 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.

   8. Many NHS records contain sensitive and/or confidential information and their destruction
      must be conducted in a secure manner to ensure there are safeguards against accidental
      loss or disclosure. The normal destruction method used within PHT is shredding. All
      confidential waste should be placed in the allocated “Shred-it” consoles or confidential waste
      bins.

   9. The secure destruction of computer media is undertaken by the ICT Department. Electronic
      records should be fully erased from Trust servers and systems.

   10. If a record 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 to destroy or alter information that has been requested, in an attempt to avoid
       disclosure.

 1. INTRODUCTION
      Disposal scheduling is an important aspect of establishing and maintaining control of corporate
      information and record resources. Not all information can be retained indefinitely. The Data
      Protection Act 1998 and the Freedom of Information Act 2000 have imposed new and more
      stringent duties on public authorities as regards to robust records management practices. The
      Trust must take steps to prevent the ad hoc disposal of records and ensure that final disposal
      of records is in accordance with legislation and key Department of Health (DoH) guidance, in
      particular, the Records Management: NHS Code of Practice (DoH 2006).

Records Retention and Disposal Policy. Issue 2. 22.12.2009      (Review date: December 2011)
                                                                                  Page 3 of 8
      This is particularly important in the electronic environment where uncontrolled copying of
      information can very easily take place. However, fully functional electronic records
      management offers a great deal to make this process more orderly, more automated and more
      secure and also delivering other substantial business benefits.

      It is recognised that the Trust needs to adopt more stringent records management practices,
      including the appropriate retention and disposal of records.


 2. PURPOSE
      This policy sets out the principles behind records retention and disposal so that records are not
      kept for longer than they are needed, and in compliance with NHS record retention schedules
      guidance by the Department of Health.


 3. SCOPE
      This policy is intended for all staff, clinical and non clinical, who hold records in both paper and
      electronic format.

      The Trust has adopted the Records Management: NHS Code of Practice (DoH 2006) which is
      the key guidance for staff. However, Trust specific information relating to retention and disposal
      of records is contained within this policy.

      This policy should be read in conjunction with the Trust Health Records Management Policy
      and the Management of Non–Clinical Records Policy.

      ‘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
      Records refer to all corporate / business records (including emails and text messages) and
      health records (e.g. patient health records, theatre and A&E registers, x-rays, audio and video
      tapes).


 5. DUTIES AND RESPONSIBILITIES
      The Chief Executive and senior managers are personally accountable for the quality of records
      management within the Trust and have a duty to make arrangements for the safe-keeping of
      the records.

      The Information Governance Manager is responsible for providing specialist records
      management advice to the organisation, co-ordinate the implementation and monitor
      compliance with this policy.

      The Trust Company Secretary is responsible for leading on the corporate records management
      function with support from the Information Governance Manager.

      The Health Records Library Operational Manager is responsible for co-ordinating the cohesive,
      efficient and effective storage, retrieval, and disposal of patient health records. The Health
      Records Library Operational Manager will authorise the destruction of health records in liaison
      with appropriate staff as required.


Records Retention and Disposal Policy. Issue 2. 22.12.2009        (Review date: December 2011)
                                                                                    Page 4 of 8
      Line managers must ensure that their staff are adequately trained in records management and
      enforce adherence to Trust Records Management policies. Senior clinicians only can authorise
      destruction of health records with written agreement from the Health Records Library
      Operational Manager.

      All Trust staff, whether clinical or administrative, who create, receive and use records have
      records management responsibilities. 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 and with any guidance subsequently produced.


 6. PROCESS
      6.1. Schedules
      The Trust follows the record retention schedules as set out in the Records Management NHS
      Code of Practice (DoH 2006) Part 2.
           Annex D1 – Health Records Retention Schedule
           Annex D2 – Business and Corporate (Non-Health) Retention Schedule

      In the event that a particular record cannot be identified within these schedules, please contact
      the Information Governance Manager for further advice.

      Revision of disposal schedules will be made by the DoH. The Information Governance
      Manager will monitor all DoH guidance and inform the Trust of any future changes made to the
      schedules and update this policy accordingly.

      6.2. Appraisal of Records
      6.2.1 The above record retention schedules outline the recommended minimum retention
      periods for all types of NHS records. The purpose of the appraisal process is to ensure that the
      record is examined at the appropriate time to determine whether or not it is worthy of archival
      preservation, whether it needs to be retained for a longer period as it is still in use, or whether it
      should be destroyed.

      6.2.2 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, and
      in accordance with the appropriate retention schedule. Guidance can be sought from the
      Information Governance Manager as required.

      6.2.3 Appraisal of health records will be undertaken by the Health Records Operational
      Manager (or person with delegated responsibility) with appropriate clinical and management
      support as required. The management of departmentally held records, i.e. GU Medicine, is the
      responsibility of the departmental managers. This applies to both paper and electronic records.
      Appendix 1 contains a flowchart showing the rules to be applied in the appraisal of records for
      destruction.

      6.3. Record Disposal
      6.3.1 Disposal of records at the end of their retention period can involve destruction or, for
      records to be permanently preserved, transfer to archives.

      6.3.2 Under the Public Records Act, NHS records over 30 years old which have been selected
      for permanent preservation and which are not in current use, must be transferred to a
      recognised place of deposit. Should such a permanent deposit be required the Information
      Governance Manager will provide guidance.

      6.3.3 Those responsible for storing records must ensure that disposal takes place in
      accordance with the retention schedule, and that disposals occur promptly and consistently.
      Regular disposal of records (including electronic records) in accordance with the retention
      schedule is vital to promote the efficient use of space and resources within the Trust and


Records Retention and Disposal Policy. Issue 2. 22.12.2009         (Review date: December 2011)
                                                                                     Page 5 of 8
      ensure that information is not retained for longer than is necessary for the purpose for which it
      was recorded to comply with Data Protection requirements.

      6.4. Destruction of Records
      6.4.1 The destruction of records is an irreversible act. Destruction of records should only take
      place in accordance with the retention schedules under 6.1. 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.

      A decision for destruction of health records must be made by a senior clinician in
      conjunction with the Health Records Operational Manager. Destruction of health records
      must not take place without recorded agreement from the Health Records Operational
      Manager

      6.4.2 Records must not be destroyed in contravention of the retention schedule without prior
      consultation with the Information Governance Steering Group.

      6.4.3 For records not already in the public domain (i.e. published or already accessible
      records), it is vital that confidentiality is safeguarded at every stage including destruction.

      6.4.4 Many NHS records contain sensitive and/or confidential information and their destruction
      must be conducted in a secure manner to ensure there are safeguards against accidental loss
      or disclosure. The normal destruction method used within PHT is shredding. All confidential
      waste should be placed in the allocated “Shred-it” consoles or confidential waste bins. Non-
      confidential waste can be placed in the recycle bins. Shredding equipment within departments
      must comply with Trust standards. The secure destruction of computer media is undertaken by
      the ICT Department. Electronic records should be fully erased from Trust servers and systems.
      Please contact the ICT Helpdesk for advice.

      6.4.5 It is a criminal offence under the Freedom of Information Act 2000 to destroy or alter
      information that has been requested, in an attempt to avoid disclosure.

      6.4.6 If a record due for destruction is known to be the subject of a request for information,
      destruction should be delayed. Once the information request is completed, the record should
      be retained until the complaint and appeal provisions of the Freedom of Information Act have
      been exhausted.

 7. TRAINING REQUIREMENTS
      The Information Governance Manager incorporates records management training within Trust
      Induction for all new starters, within Risky Business for clinical staff and as part of the e-
      learning induction package for junior doctors.

      An Information Governance e-learning package which includes records management is
      available on the Learning and Development “I am in the Moodle” website. Records
      Management e-learning modules are also available through the NHS Connecting for Health
      Information Governance Training Tool.

      The Health Records Library Manager will provide departmental health records related training
      on request.

 8. REFERENCES AND ASSOCIATED DOCUMENTATION
      Records Management: NHS Code of Practice 2006
      http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
      DH_4131747

      Public Records Act 1958
      http://www.nationalarchives.gov.uk/documents/public-records-act1958.rtf
Records Retention and Disposal Policy. Issue 2. 22.12.2009      (Review date: December 2011)
                                                                                  Page 6 of 8
      Freedom of Information Act 2000
      http://www.opsi.gov.uk/Acts/acts2000/ukpga_20000036_en_1

      The Data Protection Act 1998
      http://www.opsi.gov.uk/Acts/Acts1998/ukpga_19980029_en_1

      Lord Chancellor’s Code of Practice on the Management of Records under Section 46 of the
      Freedom of Information Act 2000.
      http://www.justice.gov.uk/guidance/docs/foi-section46-code-of-practice.pdf


      Trust Data Protection Policy
      Trust Clinical Records Management Policy
      Trust Non-Clinical Records Management Policy
      Trust Freedom of Information Policy



 9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
    PROCEDURAL DOCUMENTS
      Compliance with this policy will be monitored through two key performance indicators:

             Annual staff Information Governance Awareness Survey will monitor staff awareness of
              Records Management and records destruction issues. Results of the Survey will be
              reported to the Information Governance Steering Group and gaps in awareness
              addressed Trust-wide and through Divisional Governance arrangements where
              appropriate.
             Part of the review process for this policy is an item on the Information Governance
              Steering Group agenda for reports from the Health Records Library, where issues
              relating to records retention and destruction will be highlighted.

      As required, significant issues will be escalated to the Governance and Quality Committee
      through the IGSG quarterly reports.




Records Retention and Disposal Policy. Issue 2. 22.12.2009     (Review date: December 2011)
                                                                                 Page 7 of 8
 Appendix 1

                                    RECORD DESTRUCTION FLOWCHART


             MIS                   Patient age > 25 and patient does not have Oncology
            Query                   case note

                                   OR

                                   Patient dead > 8 years and Patient last episode end
                                    > 8 years




                                                 ________
              List to                            ________
              Review                             ________
                                                 ________
                                                 ________
                                                 ________
                                                 ________
                                                 ________
                                                 ________
                                                 ____



                                          Is patient on           Y
                                          Clinical Trials                         Retain in
                                            register?                             storage



                                            N



                                            Is patient
                            Y                 male?


    Destroy
    record
                                             N



                                          Does record
                                         have maternity
                                          episode < 25
                        N                                              Y
                                           years old?




Records Retention and Disposal Policy. Issue 2. 22.12.2009            (Review date: December 2011)
                                                                                        Page 8 of 8

								
To top