The Newcastle upon Tyne Hospitals NHS Foundation Trust. Occupational Health Records Management and Retention Operational Policy

Transcription

1 The Newcastle upon Tyne Hospitals NHS Foundation Trust Occupational Health Records Management and Retention Operational Policy Version No. 1.0 Effective From: 9 October 2013 Expiry Date: 30 September 2016 Date Ratified: 9 July 2013 Ratified by: Clinical Records Advisory Committee 1 Introduction 1.1 A clinical record is defined as a record consisting of information about the physical or mental health or condition of an identifiable individual made by or on behalf of a health professional in connection with the care of that individual. It may in a computerised form or in a manual form or a mixture of both. 1.2 This policy details the specific procedures and responsibilities for the management of Occupational Health clinical records within the department and the processes that are in place to ensure the security and safety of the information held. 2 Scope This policy relates to all Occupational Health clinical records created within the Occupational Health & Wellbeing Service and aims to provide a framework for the management of paper and electronic records in order to support the delivery of clinical care. Management of the clinical record is the responsibility of all staff within the Occupational health & Wellbeing Service staff and is not limited to clinical staff. These guidelines need to be read in conjunction with the Trust Records Management Policy and do not replace the requirements of the Trust s Clinical Record Keeping Policy. 3 Aims 3.1 This policy outlines the fundamental requirements of sound clinical records management processes in order to ensure that a comprehensive system for the storage and retrieval of clinical records is in place. 3.2 This policy outlines the roles and responsibilities of all parties. It outlines the requirements for Occupational Health records management and retention. 4 Roles and Responsibilities 4.1 Chief Executive The Chief Executive has overall responsibility for all Records Management in the Trust. Page 1 of 12

2 4.2 Caldicott Guardian The Medical Director is the Trust s Caldicott Guardian and has lead responsibility at Trust Board level for clinical records management within the organisation. 4.3 Clinical Records Advisory Committee The Clinical Records Advisory Committee is responsible for ensuring that these guidelines are implemented and that the records management systems and processes are developed, co-ordinated and monitored. 4.4 Lead Nurse Manager - Occupational Health & Wellbeing Service The Occupational Health, counselling, psychology and physiotherapy records are managed as one unit by the Lead Nurse Manager - Occupational Health & Wellbeing Service and will conform to this policy. 4.5 All Staff All staff within the Occupational Health & Wellbeing Service, whether clinical, or administrative, should be provided with appropriate training on induction and beyond to ensure that they are aware of their personal responsibilities in respect of clinical record keeping and records management. 5 Creation of records 5.1 All clients who are assessed or attend the Occupational Health & Wellbeing Service will be registered onto the Cohort OH System (Cohort) through the creation of a unique clinical record. Records are developed on a chronological basis within Cohort and/or ADOS following each contact. 5.2 Clinical records will be developed and maintained in line with the Clinical Record Keeping Policy so far as applicable to the Occupational Health & Wellbeing Service. 6 Forms of record 6.1 Occupational Health records will be differentiated between Trust staff occupational health records and occupational health records for clients of contracted external organisations Trust staff- Records will be held electronically in the Cohort system and will contain immunisation records, activity and attendance including clinical notes, s and other relevant information. Paper documents that are to be added to the record will be scanned and held in the ADOS record management system Other organisations- The Occupational Health & Wellbeing Service provides services to a range of external organisations. New clients will Page 2 of 12

3 be registered in Cohort in order to monitor and report appointment activity and to enable immunisation recall processes only. Clinical records will be held in paper format within a plastic sleeve in the appropriate contract folder for the organisation. This will facilitate transfer of records should the contract be terminated at a future date. 6.2 All Occupational Health clinical records are held separately from any other staff record within the Trust. There is no relationship or sharing arrangement with staff records held by Human Resources, the manager or Trust medical records where the staff member may have been a patient of the Trust. 6.3 Other clinical records created and held by the Occupational Health & Wellbeing Service are for: Physiotherapy- physiotherapy records will be created for clients and held by the treating physiotherapist in a secure location within either the Worklife & Wellbeing Centre or in the physiotherapy departments at either RVI or Freeman Hospitals. Once complete the physiotherapy records will be transferred to the Worklife & Wellbeing Centre for inclusion within the client s Occupational Health record Counselling- Counselling clinical records are held separately from the client s Occupational Health record and are secured in locked cabinets within the Psychology and Counselling department. These records are held in paper format only Psychology- Psychology clinical records are held separately from the client s Occupational Health record and are secured in locked cabinets within the Psychology and Counselling department. Psychology records are held in paper format only. Where a clinical psychology report is produced for a member of the Occupational Health team a copy will be maintained in the psychology records and the report will be held within the client s ADOS record. 7 Access to Occupational Health Records 7.1 The Data Protection Act 1998 gives every living person or their authorised representative, the right to apply for access to their health records irrespective of when they were compiled. Access to the health records of deceased persons is governed by the Access to Health Records Act The Occupational Health clinical record will be "sensitive personal data" for the purposes of the Data Protection Act 1998 and as such cannot be processed without the consent of the employee. 7.3 No confidential information from the clinical record should be passed to any other person outside the occupational health services without the written consent of the employee concerned, unless the disclosure is a requirement: imposed by a judge or court of law; to satisfy specific legislative requirements; or Page 3 of 12

4 due to someone exercising statutory powers that enable them to receive such information, i.e. NMC. 7.4 Access Process An application for access to an Occupational Health record or to any part of a health record may be made to the holder of the clinical record Application for immunisation records must be made in writing using wherever possible, the pre-printed request form (Appendix 1) and directed to the Occupational Health Nursing team Applications for access to records under the terms of the Act must be made in writing using, wherever possible, the standard pre-printed request form (Appendix 2) and directed to the Lead Nurse Manager- Occupational Health & Wellbeing Service A separate application must be made for copies of counselling and or psychology records as these are not considered to be part of the Occupational Health record Once a request has been received the Lead Nurse Manager should acknowledge receipt of the application in writing and also advise the applicant of the timescale for dealing with the request; within 21 days of payment When the Occupational Health record has been obtained the clinician who is involved or was the last involved in the management of the client will be notified and will decide whether there are grounds for preventing complete access or denying any access Once access has been granted the client or his/her representative should be allowed to either inspect the clinical record within the Worklife and Wellbeing Centre or receive photocopies of the relevant record A fee, not exceeding the maximum prescribed under Section 21 of the Data Protection Act 1998 plus standard photocopying charges where applicable will be charged for access to records that have not been added to within the previous 40 days. For records that are held entirely electronically on Cohort the fee will be 10 For records that are held either entirely in paper form or partly electronically and partly on paper; the fee will be a maximum of 50 For a single request of a client s immunisation records only, the fee will be free of charge. Repeat requests will be subject to a charge of 10. Page 4 of 12

5 7.5 Correction of the Clinical Record If a client considers an entry in the clinical record to be inaccurate he/she may apply in writing to have the entry corrected. These requests must be directed to the Consultant Occupational Health Physicians or Lead Nurse who will liaise with the relevant clinician If the clinician and the Consultant Occupational Health Physician/Lead Nurse are satisfied that the information is inaccurate, the necessary correction will be made If the client is not satisfied with the outcome this must be recorded in the clinical record with a description of which information is considered by the applicant to be inaccurate In either case, without requiring any fee, the Consultant Occupational Health Physician/Lead Nurse should supply the Applicant with a copy of the correction or note. 8 Transfer of records on termination of contract 8.1 Where the provision of Occupational Health Services is transferred from the Occupational Health and Welling Service the following processes will be applied. 8.2 Consent and Tracking of records The informed written consent of the employee is required to allow transfer of their occupational health records. This is both a legal and ethical requirement. This will be obtained by the new employer (the Receiving OHS) who is seeking the notes. See appendix Newcastle upon Tyne Hospitals NHS Occupational Health Service has a secure system of storage and retrieval of OH records, and ensures easy access to records if required for medico-legal purposes To allow tracking of records the Newcastle upon Tyne Hospitals NHS OH Service keeps an appropriate documentation system indicating to whom and to where OH records have been forwarded and the date the records were transferred. The documentation details the first destination the records were forwarded to. The reason for holding this information is made clear to the individual in accordance with the Data Protection Act. 8.3 Method of Transfer On receipt of the informed, written consent from the Receiving OHS, the Sending OHS will transfer the records using the approved method. This will require the records to be double enveloped and clearly addressed to a named individual at the Receiving OHS. Page 5 of 12

6 8.3.1 The full postal address of the Receiving OHS must be used, including the postcode. The envelope must be marked Confidential and the name and address of the Sending OHS will be on the back. Alternatively the receiving OHS will personally collect the records Records will be transferred through the Royal Mail Recorded Delivery Service, or an equally secure method of transfer When transferring to a NHS OH provider who uses nhs.net , the records can be provided electronically if scanned as a PDF file and appended to an . In these circumstances the sending OHS must ensure that the receiving address is correct and part of nhs.net and/or password protected Records may be transferred by fax where the receiving fax machine is known to be secure and designated as a Safe Haven Fax. Ordinarily this will be limited to transfer of immunisation records or individual reports. 8.4 Acknowledgement of Receipt In order to provide assurance that the records have reached their intended destination, the receiving OHS must sign and return a confirmation of receipt to the sender. This will be included in standard record transfer documentation (Appendix 4) An electronic receipt can be sought as an automatic process when the record is sent via nhs.net or password protected Scrutiny of Records Prior to Transfer and copying if required The Occupational Health and Wellbeing Service will consider whether they wish to keep a copy of relevant Occupational Health Records when forwarding these on to another OHS. A consultant or senior nurse must scrutinise a record before it is sent so that copies can be made of any aspects, which they feel could lead to litigation. Electronically scanning the documents is another option. 9 Records Retention 9.1 Should an employee terminate their employment from the NHS or contracted employer, the Occupational Health & Wellbeing Service will retain the records for the following minimum periods: Occupational Health Records- Because these records may contain health surveillance information they will be held for forty years in accordance with COSHH regulations. Records that are likely to contain radiological information will be retained for fifty years. Psychology and counselling records- Will be held for twenty years in accordance with interpretation of Mental Health Act Page 6 of 12

7 9.2 Original records being scanned into the ADOS system will be destroyed by secured shredding once they have been validated onto the ADOS system in accordance with BIP008 compliant processes. 10 Records Security 10.1 All OH, physiotherapy, psychology and counselling clinical records are held within secure, locked areas inaccessible to the general public and access to all clinical records stores is security controlled Access to paper based Occupational Health records will be restricted to Occupational Health & Wellbeing Staff only and managed in accordance with the Local Policy for Confidentiality relating to Occupational Health Records and Release of Occupational Health Information Movement of records internally and externally should comply with the Trust s Confidentiality and Security Policy and the Local Policy for Confidentiality relating to Occupational Health Records and Release of Occupational Health Information Paper clinical records will be secured in locked Cabinets and rooms using keys and or numeric key pads. Keys will be retained in a secured key cabinet within the department. A list of record locations is held with a declaration that keys are only accessible to Occupational Health and Wellbeing staff Electronic Cohort OH records will be stored on an external server under contract with the software provider. Electronic ADOS records will be maintained by Information Services in accordance with the Access Control Policy. 11 Training Case note management training is available to all Trust personnel via the Trust Training Department. This is a 2 hour session that should be booked in advance. Assistance at an individual level can be obtained from the Library Managers at RVI and Freeman sites. 12 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way services are provided and the way staff are treated reflects their individual needs and does not unlawfully discriminate against individuals or groups. This policy has been properly assessed. Page 7 of 12

8 13 Monitoring Compliance with the Policy Standard / Monitoring and Audit Process/ Issues Method By Committee Frequency Forms of records Audit Senior OH Team OH Management Committee Rolling Monthly Programme Access requests Audit Senior OH OH Management Yearly Team Committee Transfer Requests Audit Senior OH OH Management Yearly Team Committee Records Retention Audit Senior OH OH Management Yearly Team Committee Records Security Audit Senior OH Team OH Management Committee Quarterly 14 Consultation and review This policy has been raised at the Clinical Records Advisory Committee and the Occupational Health Management Committee. 15 Implementation of Policy (including raising awareness) Implementation and awareness of the policy will be raised with all Occupational Health and Wellbeing staff through internal training. 16 References Management of Health and Safety at Work Regulations 1999 Control of Substances Hazardous to Health Regulations 2002 Data Protection Act 1998 Control of Asbestos at Work Regulations 2002 Ionising Radiation Regulations Associated Documentation Access Control Policy Clinical Records Management Policy Clinical Record Keeping Policy Local Policy for Confidentiality relating to Occupational Health Records and Release of Occupational Health Information Occupational Health and Wellbeing Service- Operational Policy Produced by: Lead Nurse Manager- Occupational Health & Wellbeing Service Clinical Records Advisory Committee Page 8 of 12

9 Appendix 1 NHS Foundation Trust Occupational Health Service WorkLife & Wellbeing Centre Level 2, NCCT Building (15) Campus for Ageing & Vitality (NGH) Westgate Road Newcastle upon Tyne NE4 6BE Tel: Confidential (Safe Haven) Fax: Request for Information from an Occupational Health Record I would like to request a copy of the following information from my Occupational Health Record. Immunisation details, including photocopies of recent laboratory reports Surname (Please Print)... First Name (Please Print).... Date of Birth... Current Home Address... Contact Telephone Number Please advise on the following: Position Held:.. Department/Location place of work:.. Please indicate whether you will collect the information from the Occupational Health Department at the above address or if you wish it to be posted to your current home address. Collect Post Signature: Date:.... OCCUPATIONAL HEALTH PROFESSIONAL COMPLETING FORM Name (Print): Signature: Date: Page 9 of 12

10 Appendix 2 Personal details Surname Forename Address NHS Foundation Trust APPLICATION FOR ACCESS TO OCCUPATIONAL HEALTH RECORDS Post code Date of Birth Telephone number National Insurance Number If you were known to the Occupational Health & Wellbeing Service by a different name please provide evidence to support your request, for example, copy wedding certificate, Deed poll document. Declaration I declare that I am the patient and that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record referred to above under the terms of the Data Protection Act Signature...Date... Page 10 of 12

11 APPENDIX 3: Example of wording for advising staff of transfer of Occupational health records: As part of the ( insert Trust or organisation name) continuing programme of ensuring the provision of efficient and well-managed services that meet the current and changing needs of ( insert Trust or organisation name) and its staff, all staff will now be provided with an occupational health service from ( insert new Provider name). ( insert new Provider name) are a specialist Occupational Health provider with considerable experience of delivering Occupational Health Services. In order for us to provide a seamless service, we will shortly be forwarding all Occupational Health records currently held by the (current Provider name) to ( insert new Provider name),if, however, you have concerns over your records to being transferred to our new service provider, you should notify your HR Adviser in writing of your decision by (insert date). If we do not hear from you by this date we will assume your consent. (current Provider name) are bound by the provisions of the Data Protection Act to ensure that your details remain confidential and are not disclosed to a third party without your express consent. Please note that by declining to allow your records to be transferred to, this may prevent ( insert new Provider name) from providing you with a full range of Occupational Health Services. Both (insert new Provider name) and (insert Trust or organisation name) are committed to delivering a service that benefit its staff over the coming months and years. If you have any concerns or issues, please contact :- HR: Tel no: . Page 11 of 12

12 APPENDIX 4: As a participating service in the Occupational Health Records Transfer Scheme, please complete this confirmation of receipt form and return it as soon as possible to the OH Service that has forwarded the records to you. 1. Details of Sending NHS OHS: Name of Head of Occupational Health Service:.. Address of Service:... Post Code.. Phone Number.. Contact Person.. 2. Details of Receiving NHS OH Service: Name of Head of Occupational Health Service:.. Address of Service: Post Code... Phone Number Contact Person. 3. Details of Occupational Health Records: A separate list needs to include: First Name(s) Surname Date of Birth Occupation Work Location Page 12 of 12

13 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST IMPACT ASSESSMENT SCREENING FORM A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Policy Title: Occupational Health Records Management and Retention Operational Policy Policy Author: Ray Fagg Yes/No? You must provide evidence to support your response: 1. Does the policy/guidance affect one group less or more favourably than another on the basis of the following: (* denotes protected characteristics under the Equality No Act 2010) Race * No Ethnic origins (including gypsies and travellers) No Nationality No Gender * No Culture No Religion or belief * No Sexual orientation including lesbian, gay and bisexual people * No Age * No Disability learning difficulties, physical disability, sensory impairment and mental health problems * No Gender reassignment * No Marriage and civil partnership * No 2. Is there any evidence that some groups are affected differently? No 3. If you have identified potential discrimination which can include associative discrimination i.e. direct discrimination against someone because they associate with another person who possesses a protected characteristic, are any exceptions N/A valid, legal and/or justifiable? 4(a). Is the impact of the policy/guidance likely to be negative? (If yes, please answer sections 4(b) to 4(d)). No 4(b). If so can the impact be avoided? N/A 4(c). What alternatives are there to achieving the policy/guidance without the impact? N/A 4(d) Can we reduce the impact by taking different action? N/A Comments: Action Plan due (or Not Applicable): Name and Designation of Person responsible for completion of this form: Ray Fagg Lead Nurse Manager- Occupational Health & Wellbeing Date: 09 th July 2013 Names & Designations of those involved in the impact assessment screening process: Ray Fagg Lead Nurse Manager- Occupational Health & Wellbeing Service (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified on this form, please refer to the Policy Author identified above, together with any suggestions for the actions required to avoid/reduce this impact.) For advice on answering the above questions please contact Frances Blackburn, Head of Nursing, Freeman/Walkergate, or, Christine Holland, Senior HR Manager. On completion this form must be forwarded electronically to Steven Stoker, Clinical Effectiveness Manager, (Ext ) steven.stoker@nuth.nhs.uk together with the procedural document. If you have identified a potential discriminatory impact of this procedural document, please ensure that you arrange for a full consultation, with relevant stakeholders, to complete a Full Impact Assessment (Form B) and to develop an Action Plan to avoid/reduce this impact; both Form B and the Action Plan should also be sent electronically to Steven Stoker within six weeks of the completion of this form. IMPACT ASSESSMENT FORM A October 2010