Record Management Policy

Transcription

1 Record Management Policy Author: Kate Ayres, Governance Facilitator Owner: Fiona Jamieson, Assistant Director of Healthcare Governance Publisher: Compliance Unit Date of first issue: March 2006 Version: 7.0 Date of version issue: April 2013 Approved by: Information Governance Group Date approved: 19 th March 2013 Review date: April 2015 Target audience: All medical, nursing and midwifery, Allied Health Professionals, administrative and clerical staff Relevant Regulations and Standards Connecting for Health Information Governance Toolkit RMSAT Standards Executive Summary This policy sets out the standards for record keeping, record maintenance, storage and disposal of Trust records.

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3 Version History Log This area should detail the version history for this document. It should detail the key elements of the changes to the versions. Version Date Approved Version Author Status & location Details of significant changes 4.0 November 2007 Kate Ayres Archived Inclusion of guidelines on the creation, record keeping, disposal and identification f vital records 5.0 Kate Ayres Archived Revised to reflect change in format and to conform with the Development and Management of Policies Policy 5.1 Kate Ayres Archived Change of name to make less ambiguous. Inclusion of process flowcharts 6.0 March 2013 Kate Ayres On Staffroom Significant re-write of the old policy, incorporating the Clinical Record Keeping, Nursing and Midwifery Documentation and Records Management Policies. Also a breakdown of each discipline record keeping standards and including community record keeping. Records Management Policy Page 3 of 22

4 Contents Number Heading Page Process flowchart 6 1 Introduction & Scope 7 2 Definitions / Terms used in policy 7 3 Policy Statement 8 4 Equality Impact Assessment 9 5 Accountability 9 6 Consultation, Assurance and Approval Process 7 Review and Revision Arrangements 10 8 Dissemination and Implementation Dissemination Implementation of Policies 11 9 Document Control including Archiving Monitoring Compliance and Effectiveness Process for Monitoring Compliance and Effectiveness 10.2 Standards/Key Performance Indicators Training Trust Associated Documentation External References Appendices A Equality Impact Assessment Tool B Checklist for Review and Approval C Plan for Dissemination of Policy D Process for Managing Records E Record Keeping Standards Medical Staff F Record Keeping Standards Nursing and Midwifery Staff Records Management Policy Page 4 of 22

5 G Record Keeping Standards Pharmacists H Record Keeping Standards Dieticians I Record Keeping Standards Physiotherapists and Occupational Therapists J Record Keeping Standards Community Nurses K Human Resources Records L Diary Management Standards M York Casenote Structure N Scarborough Casenote Structure O Retention Schedule P Abbreviations List Records Management Policy Page 5 of 22

6 Process flowchart CORPORATE RECORDS CREATION When creating a new record, think about how the record will be named. This can either be numerical, alphabetical, or a hybrid of both. At this point consideration should be given to how long the record should be retained for. STORAGE The security of records must be paramount. This is especially important if the records.contain sensitive or personal information. Consider who needs to access the records.appropriate secure storage can be a locked desk, a locked filing cabinet or a locked office TRACKING Either a manual or electronic tracking system can be used depending on the volume of records to be tracked and who will have responsibility for tracking. Audits should be.undertaken to ensure compliance with the tracking system on a regular basis USING Usage of Trust records must comply with the record keeping standards appended to this.policy and other local procedures DISPOSAL.The retention period of each record type should be identified when the record is created Once that time period is reached the record should be reviewed and a decision taken on.whether the record has further value or can be destroyed or archived HEALTH RECORDS CREATION When issuing a health record, use the number of the front of the record folder. New records for York patients are strictly numerical and new Scarborough records are prefixed with a letter. STORAGE Security of records must always be paramount. Consideration should be given to appropriate storage of records. Health records libraries should be closed to staff outside the department and access controls should be in place to minimise the risk of unauthorised access. Records must always be secured when not in use, this can either be in a locked office or lockable filing cabinet, whichever is appropriate. TRACKING Casenotes must be tracked out in the Casenote Tracking module of CPD. Monthly audits are undertaken by Health Records staff to monitor compliance with the system and errors will be acted upon by the Health Records Department. At York Hospital notes should be tracked in to the new location by the person moving the notes. At Scarborough Hospital and the Community sites records must be tracked out of the old location and tracked into the new location. If your records are barcoded and you have a barcode reader, this must be used to minimise the risk of errors. USING Usage of health records must comply with Trust policies and procedures on record keeping and tracking. New casenotes must be generated for patients attending from Hull, Castle Hill, Goole and Beverley hospitals. DISPOSAL Remember that different retention periods apply to different record types. Always check the Trust Retention Schedule if you are unsure. If you have storage issues please contact Sally Grabham, Records Services Manager for advice Records Management Policy Page 6 of 22

7 1 Introduction & Scope The systematic process of managing records is important for the Trust in ensuring our compliance with the Freedom of Information Act 2000, the Data Protection Act 1998, the Lord Chancellor s Code of Practice on the management of records under Section 46 of the Act and the Department of Health Records Management Code of Practice. High quality evidence-based healthcare is underpinned by high quality records. The fundamental principles of accurate recording are integral in providing high quality healthcare. Records are only useful when accurate, available and maintained and an effective records management service is crucial in facilitating this process. Records management forms part of the Trust s annual assessment of the Information Governance Toolkit. An effective records management programme has many benefits for the organisation such as increased efficiency, better risk management, improved patient care and improved information security. Records management principles are applicable to both manual (paper) records and electronic records and both should be handled in accordance with this Policy. This Policy applies to all York Hospital NHS Foundation Trust staff who handle clinical or corporate records. This Policy will detail the processes for managing records through their life. This includes: - Creation - Retrieval - Retention and disposal - Maintenance and record keeping 2 Definitions / Terms used in policy Records Management This is a discipline which utilises an administrative system to direct and control the creation, version control, distribution, filing, retention, storage and disposal of records, in a way that is administratively and legally sound, whilst at the same time serving the operational needs of the Trust and Records Management Policy Page 7 of 22

8 preserving a historical record. The key components of records management are: Record creation Record keeping Record maintenance (including tracking of record movements) Access and disclosure Closure and transfer Appraisal Archiving Disposal Record Life Cycle The life of a record from its creation/receipt through the period of its active use then into a period of inactive retention and finally either confidential disposal or archival preservation Records Defined as recorded information, in any form, created or received and maintained by the Trust in the transaction of its business or conduct of affairs and kept as evidence of such activity Information This is a corporate asset. The Trust s records are important sources of administrative, evidential and historical information. They are vital to the Trust to support its current and future operations, for the purpose of accountability, and for an awareness and understanding of its history and procedures 3 Policy Statement The Trust is committed to effectively managing its records in accordance with the Freedom of Information Act, the Data Protection Act and guidance from both the Department of Health and the Information Commissioner. The process for the management of clinical and corporate records is detailed at Appendix D. The record keeping standards for the various disciplines across the organisation are detailed at appendices E to K. Records Management Policy Page 8 of 22

9 4 Equality Impact Assessment The Trust statement on Equality is available in the Policy for Development and Management of Policies at Section A copy of the Equality Impact Assessment for this policy is at appendix A. 5 Accountability Chief Executive The Chief Executive has overall responsibility for records management in the Trust. As accountable officer he/she is responsible for the management of the organisation 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. The Trust has a particular responsibility for ensuring it corporately meets its legal responsibilities, and for the adoption of internal and external governance requirements. Caldicott Guardian The Trust s Caldicott Guardian has a particular responsibility for reflecting patients interests regarding the use of patient identifiable information. They are responsible for ensuring patient identifiable information is shared only in an appropriate and secure manner. Information Governance Group The Trust Information Governance Group are responsible for ensuring that this policy is implemented, through the Records Management Strategy, and that the Strategy is monitored. All Staff 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. Records Management Policy Page 9 of 22

10 Contractors and Support Organisations Service Level Agreements and contracts must include responsibilities for information governance and records management as appropriate. The Information Governance Team will conduct Compliance Reviews in all corporate and clinical areas to ensure staff are complying with the policy. The findings and recommendations will be taken to the Information Governance Committee and action plans will be monitored. 6 Consultation, Assurance and Approval Process 6.1 Consultation This Policy has been produced following consultation with the following individuals: Caldicott Guardian Assistant Director of Healthcare Governance Head of Patient Access Records Services Manager AHPs, Pharmacy, Radiology, Dietetics and Community Nursing 6.2 Assurance Following consultation with stakeholders and relevant consultative committees, this policy has been reviewed by the authorising committee to ensure it meets the NHSLA standards for the production of policy documents. 6.3 Approval Process This policy was approved by the Information Governance Committee in March Future revisions of the Policy will be approved by the Information Governance Committee. 7 Review and Revision Arrangements The date of review is given on the front coversheet. Person responsible for review are: Records Management Policy Page 10 of 22

11 Information Governance Manager (Records Management) The Compliance Unit will notify the author of the policy of the need for its review six months before the date of expiry. On reviewing this policy, all stakeholders identified in section 6 will be consulted as per the Trust s Stakeholder policy. Subsequent changes to this policy will be detailed on the version control sheet at the front of the policy and a new version number will be applied. Subsequent reviews of this policy will continue to require the approval of the appropriate committee as determined by the Policy for Development and Management of Policies. 8 Dissemination and Implementation 8.1 Dissemination Once approved, this policy will be brought to the attention of relevant staff as per the Policy for Development and Management of Policies, section 8 and Appendix C Plan for Dissemination. This policy is available in alternative formats, such as Braille or large font, on request to the author of the policy. 8.2 Implementation of Policies The Policy will be available to all staff in the Corporate Documents section of Staffroom. The provision of advice on the Policy can be obtained by contacting Kate Ayres on or by . Training in records management and maintenance will be available to staff groups where the need has been identified on a departmental level. 9 Document Control including Archiving The register and archiving arrangements for policies will be managed by the Policy Manager. To retrieve a former version of this policy the Policy Manager should be contacted. 10 Monitoring Compliance and Effectiveness This policy will be monitored for compliance with the minimum requirements outlined below. Records Management Policy Page 11 of 22

12 This policy will be monitored for compliance with the minimum requirements for criteria 1.1.8, and of the NHSLA Risk Management Standards. Compliance with the policy will be as part of the Governance Facilitation Team compliance review programme. The aim of the review is to assess staff awareness with each of the Information Governance initiatives. Each area of the Trust will be assessed on its compliance with the policy, identifying areas of good practice and assisting the Department in drawing up an action plan if compliance falls short of expected standards. Additionally a bi-annual records survey will be undertaken by the Governance Facilitation Team Team. This will involve liaising with key members of staff in all departments to establish what records are held, how long they are held for and whether a retention period has been defined. It will also look at how the records are disposed of and an assessment of the type of information they contain Process for Monitoring Compliance and Effectiveness In order the fully monitor compliance with this policy and to ensure that the minimum requirements are met the policy will be monitored as follows: WHO: Monitors HOW: What are they monitoring WHEN: Frequency of monitoring TO WHOM: Who will the outcomes of monitoring be reported to? Evidence Monitoring /Who by Frequency a. DUTIES Compliance will be assessed through a rolling programme of compliance audits and records survey b. LEGAL OBLIGATIONS A bi-annual survey will be undertaken by the Information Governance Team to assess the Governance Facilitation Team Governance Facilitation Team Compliance audits ongoing Survey every 2 years Every 2 years Records Management Policy Page 12 of 22

13 Trust s compliance with its legal obligations for records management c. PROCESS FOR TRACKING RECORDS Monthly audit work is undertaken to ensure compliance with the health records tracking system d. PROCESS FOR CREATING RECORDS Bi-annual records survey will ensure that records which are created conform to prescribed standards e. PROCESS FOR RETRIEVING RECORDS Bi-annual records survey will ensure compliance with the health records tracking system f. PROCESS FOR RETENTION, DISPOSAL AND DESTRUCTION OF RECORDS Storage, review and disposal of semi-current records (those no longer in use) is provided by the Information Governance Team and therefore records are managed by a dedicated team of staff g. MONITORING COMPLIANCE Compliance will be monitored as part of a rolling programme of compliance reviews in all clinical and non-clinical areas of the Trust Health Records Staff Governance Facilitation Team Governance Facilitation Team Health Records Staff Governance Facilitation Team Every month Every 2 years Every 2 years Ongoing Ongoing Records Management Policy Page 13 of 22

14 10.2 Standards/Key Performance Indicators The records management function of the Trust is audited annually as part of the Information Governance Toolkit assessment. This required the Trust to: Conduct an inventory (survey) of its corporate records Have in place documented and implemented procedures for the creation of corporate records Have in place documented and implemented procedures for the creation, filing and tracking of corporate records 11 Training Any theoretical training requirements identified within this policy are outlined within the mandatory training profiles accessed via the Statutory & Mandatory Training Link that can be found on the home page of Horizon or on Q:\York Hospitals Trust\Mandatory Training. You will be required to create your own mandatory training profile using the tool and support materials available in these areas and agree your uptake of this training with your line manager. The training identification policy and procedure document describes the processes related to the review, delivery and monitoring of mandatory training, including non attendance. 12 Trust Associated Documentation Development and Management of Policies Policy Information Governance Policy Data Protection Policy Freedom of Information Policy Records Services Procedures Manual - Section 1: General Records Services Procedures - Section 2: Library Services Procedures Recording Hyper-sensitivities, Allergies and Alerts Procedure Advance Decisions Procedure Use of Incorrect Case Note Protocol Records Management Policy Page 14 of 22

15 13 External References National Archives guidance on the management of records - Guidance on record creation and keeping - Guidance on record maintenance 5.pdf - Guidance on record disposal Risk Management Standards for Acute Trusts NHS Connecting for Health Information Governance Toolkit Records Management Policy Page 15 of 22

16 Appendix A: Equality Impact Assessment Tool To be completed when submitted to the appropriate committee for consideration and approval. Name of Policy: Records Management Policy 1. What are the intended outcomes of this work? 2 To detail the standard for record keeping within the Trust and to inform staff on the management and maintenance of records of all types Who will be affected? All staff 3 What evidence have you considered? a b c Department of Health Code of Practice on Records Management Guidance from the Nation Archives Disability This policy is inclusive and does not differentiate between people on the basis of this characteristic Sex This policy is inclusive and does not differentiate between people on the basis of this characteristic Race This policy is inclusive and does not differentiate between people on the basis of this characteristic d Age. This policy is inclusive and does not differentiate between people on the basis of this characteristic e f Gender Reassignment This policy is inclusive and does not differentiate between people on the basis of this characteristic Sexual Orientation This policy is inclusive and does not differentiate between people on the basis of this characteristic g Religion or Belief This policy is inclusive and does not differentiate between people on the basis of this characteristic h Pregnancy and Maternity. This policy is inclusive and does not differentiate between people on the basis of this characteristic Records Management Policy Page 16 of 22

17 i Carers This policy is inclusive and does not differentiate between people on the basis of this characteristic j Other Identified Groups None 4. Engagement and Involvement a. Was this work subject to consultation? b. How have you engaged stakeholders in constructing the policy c. If so, how have you engaged stakeholders in constructing the policy Direct consultation and also via the Information Governance Group d. For each engagement activity, please state who was involved, how they were engaged and key outputs 5. Consultation Outcome Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups a b Eliminate discrimination, harassment and victimisation Advance Equality of Opportunity c d Promote Good Relations Between Groups What is the overall impact? Name of the Person who carried out this assessment: Records Management Policy Page 17 of 22

18 Kate Ayres Date Assessment Completed Name of responsible Director If you have identified a potential discriminatory impact of this procedural document, please refer it to the Equality and Diversity Committee, together with any suggestions as to the action required to avoid/reduce this impact. Records Management Policy Page 18 of 22

19 Appendix B Checklist for the Review and Approval To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: 1 Development and Management of Policies Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or procedures? 2 Rationale Are reasons for development of the document stated? 3 Development Process Is the method described in brief? Are individuals involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? Has an operational, manpower and financial resource assessment been undertaken? 4 Content Is the document linked to a strategy? Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? /No/ Unsure Comments Records Management Policy Page 19 of 22

20 Title of document being reviewed: Are the statements clear and unambiguous? 5 Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are local/organisational supporting documents referenced? 5a Quality Assurance Has the standard the policy been written to address the issues identified? Has QA been completed and approved? 6 Approval Does the document identify which committee/group will approve it? If appropriate, have the staff side committee (or equivalent) approved the document? 7 Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8 Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? /No/ Unsure Comments Records Management Policy Page 20 of 22

21 Title of document being reviewed: 9 Process for Monitoring Compliance Are there measurable standards or KPIs to support monitoring compliance of the document? Is there a plan to review or audit compliance with the document? 10 Review Date Is the review date identified? Is the frequency of review identified? If so, is it acceptable? 11 Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? /No/ Unsure Comments Individual Approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Name Signature Date Committee Approval If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation s database of approved documents. Name Signature Date Records Management Policy Page 21 of 22

22 Appendix C Plan for dissemination of policy To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Title of document: Records Management Policy Date finalised: January 2013 Previous document in use? Dissemination lead Kate Ayres Which Strategy does it relate to? Information Governance Strategy If yes, in what format and where? Proposed action to retrieve out of date copies of the document: Dissemination Grid Compliance Unit will hold archive To be disseminated to: 1) All Staff 2) Method of dissemination Who will do it? And when? Format (i.e. paper or electronic) Staff Brief IG Team Next available Electronic Dissemination Record Date put on register / library On approval Review date March 2015 Disseminated to All staff via Staffroom Format (i.e. paper or electronic) Electronic Date Disseminated N/A No. of Copies Sent Contact Details / Comments Records Management Policy Page 22 of 22