Standard Operating Procedure for the Destruction of Patient Records

Transcription

1 Standard Operating Procedure for the Destruction of Patient Records DOCUMENT CONTROL: Version: 1 Ratified by: Risk Management Sub Group Date ratified: 21 January 2015 Name of originator/author: Records Manager Name of responsible Risk Management Sub Group committee/individual: Date issued: 28 January 2015 Review date: January 2018 Target Audience All Trust Staff Page 1 of 5

2 1. Aim 1.1 The purpose of this Standard Operating Procedure is to establish a sound legal framework and consistent practice across all Trust services in the destruction and deletion of patient records compliant with the NHS Code of practice for records management. 2. Scope 2.1 This Standard Operating Procedure (SOP) applies to all staff working within the Trust, whether employed by the Trust or not; who are involved in handling patient information. 2.2 This SOP covers both paper and electronic records. 3. Link to overarching policy and/or procedure Lifecycle of Clinical and Corporate Records Policy Standard Operating procedure for Offsite Storage 4. Procedure 4.1 On an annual basis the Records Manager will pull reports from the clinical record systems which will detail records due for deletion in line with the NHS Code of Practice for Records Management. 4.2 A match of these records can then take place with any records that are offsite. All records that are 3 years past discharge date or deceased persons should be stored at offsite storage facility and therefore this process should capture all records without the need to search for records that meet destruction criteria onsite. 4.3 The Records Manager will send reports to each Steering Group representative. 4.4 The Steering Group will disseminate the lists to the correct teams via the Records Management Co-ordinators. 4.5 Each Business Division/Corporate Service/Business Support Unit will then be responsible for helping the Records Management Coordinator check and authorise that the records can be destroyed. 4.6 All patient files should be held at file level, therefore staff members will be able to see individual names, NHS Numbers etc and the file can be reviewed without it leaving the box at offsite storage. 4.7 If further information is needed from within the actual file, the file can be retrieved. When retrieved, if it is decided that the file will be destroyed, the barcodes of each file should be sent through to Records Management to allow the data to be permanently removed from the

3 offsite storage database and once destruction has been authorised destroy these, using the confidential waste bags. 4.8 There will be records at offsite that will not exist on the electronic clinical information systems. These will be dealt with separately as they will need to be retrieved and retained from the last date within the paper record. 4.9 On the report there will be columns that state the following: Date Discharged: Date reviewed: Reviewed by: Action: Retain (still within retention period) Retrieve (current record needs to be merged) Destroy (past retention period) Destroy Date: Where to be destroyed: Offsite Locally N/A Next review date: Review in 1 year Review in 5 years Review in 10 years N/A Reason to retain: Current patient, records not required for current care Current patient, records to be retrieved Overwhelming public interest Historical interest Potential claim Industrial/Hazardous exposure (Asbestos / Radiation etc) Major public health exposure / Serious notifiable illnesses (Ebola, Yellow fever etc) Other (please comment) Authorisation (Head of Service) IG/RM who authorised offsite storage: IG/RM who authorised local destruction: Actual Destruction date: 4.10 All records must be checked for any further requirement to retain, such as: Serious Incidents which extend a deceased file by an extra 2 years.

4 4.11 All files must be reviewed and the above data selected per line of record Once complete, the report must be ed to the correct Head of Service. The Head of Service must then check the report and the actions stated, then forward the to the and advise they authorise actions to be undertaken Notification will be sent to the Caldicott Guardian that records are due to be destroyed. This will be brought to the Records Group to check full destruction process has been followed Once authorised by the Caldicott Guardian and the Records Group, the Records Manager will ask for approved records that meet the criteria and are remaining at offsite to be destroyed and for the Information team to delete the entry on the clinical information system The Clinical Information Systems team will keep a database holding skeleton entries to allow us to know that a person has been known to the Trust. Skeleton data will consist of NHS Number, Name, DOB and the dates when they were a patient The returns created by the Head of Service will be compiled and treated as the destruction register and will be held with the Clinical Information Systems team overseen by the Records Manager Once the approved records have been destroyed or deleted, they will not be able to be recovered as this action is permanent In the event that some records need to be kept, a review date must be applied. They will then be reviewed when the next appropriate annual destruction criterion is met. N/A must only be selected on the report if the file is due for destruction in the report. All files must have a review date or a destruction date Records may be retained past their destruction date provided that there is business reason to do so. A list of reasons to retain is given and must be selected. There is an option for other however a comment must be given and these must be suitable business reasons. If the reasons are not satisfactory, these will be questioned by the Records Manager A review must be undertaken after a set period of years to consider whether the data held under the Data Protection Act is still relevant to the trust.

5 Flow Chart for the destruction of patient records Appendix 1 Records Manager sends out a list to the Records Management Coordinators Records Management Co-ordinators work with Business Division/Corporate Service/Business Support Unit to review records. File Level Records Box Level Records Review record Fill out the spread sheet with the action for each record. Authorise by AD and Return to Ask the Records Manager for boxes to be placed on File Level and an inventory sent to you. Once inventory received follow file level workflow. Authorise by Caldicott Guardian and Records Group Send request to Information and Offsite Storage to delete/ destroy