HEALTHCARE RECORDS MANAGEMENT

This document is uncontrolled once printed. Please refer to the Trusts Intranet site (Procedural Documents) for the most up to date version HEALTHCARE RECORDS MANAGEMENT NGH-PO-058 Ratified By: Procedural Documents Group Date Ratified: April 2014 Version No: 4 Supercedes Document No: 3.6 Previous versions ratified by (group & date): Health record committee Oct 2011 May 2011 (v3.3) May 2009 (v2) Sept 2007 (v1) Date(s) Reviewed: April 2014 Next Review Date: April 2017 Responsibility for Review: Health Records Manager Contributors: Health Records Group NGH-PO-058 Page 1 of 46 Version No: 4 April 2014

CONTENTS Version Control Summary... 3 SUMMARY... 5 1. INTRODUCTION... 6 2. PURPOSE... 6 3. SCOPE... 7 4. COMPLIANCE STATEMENTS... 7 5. DEFINITIONS... 8 6. ROLES & RESPONSIBILITIES... 9 7. SUBSTANTIVE CONTENT... 11 7.1. Aims of the Healthcare Records Management System... 11 7.2. Medical Records Department... 11 7.3. Registration... 11 7.4. Case Note Folder... 12 7.5. Creation of Record... 12 7.6. Storage of Record... 12 7.7. Tracking Records... 13 7.8. Retrieval of Record... 14 7.9. Transportation of Records... 15 7.10. Loose paperwork... 15 7.11. Retention, Disposal and Destruction of Records... 15 7.12. Electronic Documentation Management and Archiving... 15 7.13. Access to Medical Records Patient Requests... 16 7.14. Advance Directives (Living Wills)... 16 7.15. Standards of Record Keeping... 16 8. IMPLEMENTATION & TRAINING... 16 9. MONITORING & REVIEW... 17 10. REFERENCES & ASSOCIATED DOCUMENTATION... 20 APPENDICES... 22 Appendix 1 Guidelines for using the case note folder... 22 Appendix 2 Procedures for Tracing/Locating missing Healthcare Records... 27 Appendix 3 Guidance in maintaining the security and safety of NGH notes off-site... 31 NGH-PO-058 Page 2 of 46 Version No: 4 April 2014

Appendix 4 Preservation, Destruction, Microfilming, Scanning, and Off-site Storage of Health Records... 32 Appendix 5 Archiving of Healthcare Records and Electronic Healthcare Records... 35 Appendix 6 Access to Medical Records; Patient Requests... 36 Appendix 7 Living wills / advanced directives... 38 Appendix 8 Healthcare Record Standards Audit 2014 modified question-set... 39 Appendix 9 Medical Records internal record audit... 40 Appendix 10 Business continuity, emergency & major incident policy and ipm downtime... 41 Appendix 11 Contact details for medical records staff... 43 Appendix 12 Health records management... 44 Appendix 13 Terms of Reference Healthcare Records Group, Version 2... 45 Version Control Summary NGH-PO-058 Page 3 of 46 Version No: 4 April 2014

Version Date Author Status Comment 3.6 Oct 2011 Sue Collier / Health record committee 4 Feb 2014 Tracey Harris / Craig Smith / Health Records Group Ratified Ratified NGH-PO-058 Page 4 of 46 Version No: 4 April 2014

SUMMARY Northampton General Hospital (NGH) NHS Trust has a duty to provide the highest possible standard of health care to patients. This policy defines the structure and processes for the management of clinical records in all media at the Trust. The management of Healthcare Records through the proper control of content, storage, transporting and access ensures availability of records at the point of care, and reduces the risk of poor clinical care, legal challenge and financial loss. This policy is a working guide for all staff whose role involves access to healthcare records in an acute or community setting. NGH-PO-058 Page 5 of 46 Version No: 4 April 2014

1. INTRODUCTION Healthcare Records Management is the process by which an organisation manages all the aspects of healthcare records in any format or media type, from their creation, throughout their lifecycle to their eventual disposal. The Records Management: NHS Code of Practice 2006 has been published by the Department of Health as a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice. The Trust s Healthcare Records are its corporate memory, providing evidence of actions and decisions and representing a vital asset to support daily functions and operations. Records support policy formation and managerial decision-making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways. The Trust has adopted this healthcare records management policy and is committed to ongoing improvement of its healthcare records management functions as it believes that it will gain a number of organisational benefits from so doing. These include: better use of physical and server space; better use of staff time; improved control of valuable information resources; compliance with legislation and standards; and reduced costs This policy document should be read in conjunction with the Trust s Paper Health Record Improvement Strategy NGH-SY-691 which sets out how the policy requirements will be delivered. 2. PURPOSE To inform staff of the Trust requirements in relation to Healthcare records management and what is expected of staff. To protect the Trust as an employer and ensure that we comply with the relevant legislation and codes of practice. To raise the profile of Healthcare records management in the organisation. NGH-PO-058 Page 6 of 46 Version No: 4 April 2014

3. SCOPE This policy is applicable to all Trust staff that handle, use and / or have access to healthcare records of all types in the acute and community setting. To provide awareness of the duties of key staff and processes in the management of patient s healthcare records from creation to destruction including, setting up new folders, tracking and retrieval, storage and archiving and disposing of records. It also sets out the way in which the Trust will meet its legal obligations in relation to the Data Protection Act 1998, Freedom of Information Act 2000 and the standards set out by the Care Quality Commission in respect of records management. 4. COMPLIANCE STATEMENTS Equality & Diversity This policy has been designed to support the Trust s effort to promote Equality and Human Rights in the work place and has been assessed for any adverse impact using the Trust s Equality Impact assessment tool as required by the Trust s Equality and Human Rights Strategy. It is considered to be compliant with equality legislation and to uphold the implementation of Equality and Human Rights in practice. NHS Constitution The contents of this document incorporates the NHS Constitution and sets out the rights, to which, where applicable, patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with the responsibilities which, where applicable, public, patients and staff owe to one another. The foundation of this document is based on the Principals and Values of the NHS along with the Vision and Values of Northampton General Hospital NHS Trust. Legal and Professional Obligations All NHS records are Public Records under the Public Records Acts. The Trust will take actions as necessary to comply with the legal and professional obligations set out in the Records Management: NHS Code of Practice, in particular: The Public Records Act 1958; The Data Protection Act 1998; The Freedom of Information Act 2000; The Common Law Duty of Confidentiality; and The NHS Confidentiality Code of Practice. And any new legislation affecting records management as it arises. NGH-PO-058 Page 7 of 46 Version No: 4 April 2014

5. DEFINITIONS Healthcare Record Records management Record life cycle A healthcare record consists of information relating to the physical or mental health or condition of an individual and has been made by or on behalf of a health professional in connection with the care of the individual in any medium. Records management is a discipline which utilises an administrative system to direct and control the creation of information in a way that is administratively and legally sound, whilst at the same time serving the operational needs of the Trust and preserving an appropriate historical record. The key components of records management are: record creation record keeping record maintenance (including tracking of record movements and storage) Filing notes in the appropriate folder section access and disclosure monitoring and auditing closure and transfer appraisal archiving disposal The term record life cycle describes the life of a record from its creation/ receipt through the period of its active use, then into a period of inactive retention (such as closed or archived files which may still be referred to occasionally) and finally either confidential disposal or archival preservation. NGH-PO-058 Page 8 of 46 Version No: 4 April 2014

6. ROLES & RESPONSIBILITIES Role Chief Executive and Trust Board Director of Strategy & Partnerships The Health Records Group Head of Cancer & Medical Records Care Groups; General Managers & Service Managers Health Records Manager Responsibility Chief Executive and Trust Board have ultimate accountability for actions and inactions in relation to this policy. Director with overall responsibility and SIRO at the Trust The Health Records Group is responsible for agreeing, monitoring and developing health records management policy on behalf of the Trust. It oversees implementation of the policy and ensures adherence to national standards. Ensuring the policy is implemented, through the Paper health Record Improvement Strategy Agreeing and signing off tools used for auditing healthcare records Receiving and advising on the results of healthcare records audits Ensure that the audit of healthcare records is undertaken in line with this policy Making recommendations for improvements to record keeping across the Trust Reviewing this document and the standards for record keeping on an annual basis to ensure they continue to meet the needs of the Trust The Head of Cancer & Medical Records supports the nominated director, the Health Records Group and Directorates and Departments in monitoring and facilitating implementation of the policy Directorate and Department managers are responsible for ensuring adherence to the policy within their designated area. The Health Records Manager is responsible for: The function of the medical records library Transportation and tracking of healthcare records Implementation of Trust wide record keeping standards as defined and monitored by the Health Records Group Guidance to clinicians, departments and the Trust on the strategic and operational approach to the maintenance of Trust Healthcare records including Child Health, A&E and Community Midwifery NGH-PO-058 Page 9 of 46 Version No: 4 April 2014

Role Head of Information Governance Responsibility Provision of healthcare record information in accordance with the Data Protection Act 1998, Access to Health Records Act 1990 and Freedom of Information Act 2000 The Head of Information Governance is responsible for monitoring adherence to the policy and assures the Director of compliance All Trust Employees Clinical Safety Effectiveness and Audit Lead Have a responsibility to: Adhere to the content of this policy Support the Trust to achieve its Vision and Values Follow duties and expectations of staff as detailed in the NHS Constitution Staff Deal with Medical Records in a safe and responsible way File correctly within the record The Clinical Safety Effectiveness and Audit Lead is responsible for monitoring compliance with the record keeping standards, collating the audit data monthly for the Clinical Outcomes Scorecard and reporting the findings quarterly to the Healthcare Records Group., NGH-PO-058 Page 10 of 46 Version No: 4 April 2014

7. SUBSTANTIVE CONTENT 7.1. Aims of the Healthcare Records Management System The aims of the Healthcare Records Management System are to ensure that: Records are available when needed - from which the Trust is able to form a reconstruction of activities or events that have taken place (CQC Standards Outcome 21 A) Records can be accessed - records and the information within them can be located and displayed in a way consistent with its initial use, and that the current version is identified where multiple versions exist (Outcome 21 A;D) Records can be interpreted - the context of the record can be interpreted: who created or added to the record and when, during which business process, and how the record is related to other records (Outcome 21 A) Records can be trusted the record reliably represents the information that was actually used in, or created by, the business process, and its integrity and authenticity can be demonstrated (Outcome 21 A) Records can be maintained through time the qualities of availability, accessibility, interpretation and trustworthiness can be maintained for as long as the record is needed, perhaps permanently, despite changes of format (Outcome 21 A) Records are secure - from unauthorised or inadvertent alteration or erasure, that access and disclosure are properly controlled and audit trails will track all use and changes. To ensure that records are held in a robust format which remains readable for as long as records are required (Outcome 21 A) Records are retained and disposed of appropriately - using consistent and documented retention and disposal procedures, which include provision for appraisal and the permanent preservation of records with archival value; Outcome 21 B Staff are trained - so that all staff are made aware of their responsibilities for recordkeeping, filing appropriately and record management (Outcome 21 A;D) 7.2. Medical Records Department Access to the department is controlled for security purposes and is staffed 24 hours per day. Medical Records staff may be contacted by telephone (Appendix 11) or by intercom on the front door during normal office hours. Authorised staff may gain access using the swipe access (permission must be gained from the Health Records Manager before swipe access is granted). All visitors must complete the visitors log and track any healthcare records that are removed from the department. 7.3. Registration All patient attendances at the hospital should be recorded. The master computerised patient management system used by the Trust is Inpatient Manager (ipm). All users of the ipm system must receive training from an IT trainer, before a Smartcard is issued. This includes how to identify the previous record of a patient and how to newly register. If a duplicate set of Healthcare Records is found, the Medical Records Services Support Coordinator should be called immediately on extension 5113 who will investigate and correct as required. NGH-PO-058 Page 11 of 46 Version No: 4 April 2014

7.4. Case Note Folder The case note folder is supplied with designated Trust wide dividers, one Clinical Notes Sheet and a Chronology of Events Sheet. The folder will come with barcoded address labels front and back along with a sheet of small address labels in the inside cover at the front of the folder for further clinic sheets and filing. Extra dividers for Maternity and Oncology are inserted as required. Full guidelines for using the case note folder can be found in Appendix 1. 7.5. Creation of Record The first time a patient attends NGH in an emergency, for admission or for a patient clinic appointment, designated administrative staff register the patient details on ipm which issues a unique NGH hospital number. When notified, Medical Records staff will create a new paper healthcare record folder using this number. For audits and non-medical occasions other designated administrative staff may create a new paper healthcare folder. Every effort is made to ensure that duplicate registrations are minimised. This is monitored by the Medical Records Services Coordinator during office hours and any duplicate healthcare records where applicable are merged. Where patients have previously attended NGH but their case notes have been archived to Optical Disk a paper case note folder is created with a new volume number by Medical Records staff. DOCUMENTUM must be checked for any patient alerts such as allergies and safeguarding. Where patients have previously attended NGH but their case notes have been archived to Microfilm the paper case note folder is recreated using the same volume number. The Microfilm must be checked for any patient alerts such as allergies and safeguarding. In both events the alerts should be hand written in BLOCK capitals and the Microfilm or Archived box ticked. 7.6. Storage of Record When not in use, healthcare records should be stored in the Medical Records Library unless previously agreed with the Health Records Manager. When healthcare records meet the specific criteria then healthcare records will be securely stored at an off-site storage facility or archived (Appendix 4 & 5). When healthcare records are in use it is up to the person/department that is using them to keep them in a secure area and to avoid any damage to the case note folder. 7.6.1. On Site Within the Medical Records Department healthcare records are stored in the main library with some larger volumes stored in secure cabins situated across the road from the main department. Healthcare records may be tracked to other sub-departments of Medical records such as Archiving, Access, Clinical Coding or various teams as required. On these occasions the notes should be tracked in accordance with this policy. Within the Trust the notes should be tracked in on receipt and stored in a secure location within that department that is known and accessible to Medical Records staff for emergencies. If notes are moved from this agreed secured location (e.g. by a clinician) then a local tracer should be in place with access. NGH-PO-058 Page 12 of 46 Version No: 4 April 2014

7.6.2. Off Site a) Archive Storage Some archived records may be stored off site at an archiving and storage company with whom NGH has a data management contract. Any request for separate or individual records to be stored offsite must be agreed by the Health Records Group and co-ordinated through the Archiving Supervisor. There are two accounts for records stored off site, these are; a live account where records which have been inactive for over 2 years for adults and 5 years for children under the age of sixteen, a RIP account where deceased patient s records are stored after eighteen months in NGH. Routine medical record requests can be obtained within twenty-four hours but for emergencies there is an agreed two hour response time. Further information can be found in Appendix 5 b) Managing Healthcare Records in the Community When managing healthcare records in the community the following guidelines apply: Patient records for peripheral clinics/hospitals/community care must be delivered to a designated area agreed with the Health Records Manager. On delivery, the security and confidentiality of the record becomes the responsibility of that hospital/medical centre and its staff members. Each hospital/medical centre will identify a lead person to hold this responsibility. The named member of staff to whom records are booked must be aware of the record s exact location at all times. Removal to a non-designated area is not permitted. A member of staff must return records to NGH on the next available hospital transport or immediately after clinic. On those occasions when the patient records must remain on the site of the clinic/hospital overnight it is the responsibility of the Senior Manager of the peripheral clinic/hospital to ensure those patient records are kept in a secure area. Measures must be in place for the timely retrieval of a patient record if requested by Medical Records staff out of normal office hours, in the event of the record being required for an emergency attendance or admission. (This includes Community Midwives, Child Health notes etc.) It may be necessary to photocopy a portion of the main healthcare record for clinical use in a community setting. Only that section relevant to the Consultation may be photocopied. Patient confidentiality must be maintained when copying. Duplicated information should be confidentially destroyed immediately following patient contact. Clinicians must abide by the guidelines Appendix 3 in maintaining the security and confidentiality of the healthcare record when used in a community setting. 7.7. Tracking Records It is vital that healthcare records are available to clinical staff at the point of care whether that is during normal office hours or out of hours. To achieve this, healthcare records should always be tracked electronically as they move from department to department using the ipm system. All wards and clinic receptions are issued scanners to track large volumes of notes and training is available for their use. Electronic tracking provides all staff an accurate audit trail in order to ensure immediate location. NGH-PO-058 Page 13 of 46 Version No: 4 April 2014

Healthcare records should be tracked in and out of Medical Records and at each point when the records change location (e.g. changing wards). Healthcare records are tracked either to a named member of staff who is responsible for ensuring their safe keeping while in their care, and the recording of location changes, or to a ward where this is the responsibility of the ward manager. Failure to track healthcare records correctly may result in the loss or misfile of the notes and lead to patient care being compromised or procedures cancelled along with several hours of time lost in trying to locate them. If a set of notes are tracked to an individual that individual is responsible for the whereabouts of them and their security, failure to control healthcare records that are in the care of an individual may result in disciplinary action or prosecution under this Policy and in serious instances the Data Protection Act 1998. All staff handling healthcare records must maintain the highest standards of confidentiality All healthcare records are to be tracked using ipm, scanners have been provided to clinic receptions and wards. Under no circumstances should healthcare notes be tracked in or out of departments using batch lists or clinic lists. 7.8. Retrieval of Record Availability of healthcare records will be monitored by the Health Records Manager. A complete healthcare record must be available whenever a patient attends a clinic or is admitted to hospital. For Routine Outpatient clinics including some TCIs an initial patient list is generated from ipm and printed by the IT Department seven days prior to the appointment. This is followed by a further list two days before the clinic for extra patients and cancelations. This allows time for Medical Records staff to find healthcare records that are not located within the department and request any notes that are held off site. In the event of extra patients, walk ins, or on the day and other short notice requests Medical Records staff will endeavor to retrieve notes on the understanding that there may be delays due to the location of them. Routine clinics will be available at least two days before clinic date to allow preparation time unless agreed between departments. Community clinics such as Daventry outpatients will be ready for transporting at the end of the working day two days before clinic date. A&E requests are received via telephone to the admissions clerks, these requests are to be actioned within 30 minutes of the request, for case note folders that are held off site this is extended to two hours. NGH-PO-058 Page 14 of 46 Version No: 4 April 2014

Emergency admissions including Wards, Paediatrics, Eye Casualty and Ambulatory Care are requested in the same way as A&E, although notes for EAU and Benham are requested by an email generated through Symphony. They will be actioned within two hours of the request, for case notes that are held off site this will be discussed with the requestor to agree whether this request is required within a 2 hour window or can be obtained as a routine off site retrieval. For any healthcare record that cannot be found for a clinic or TCI, please follow the procedure for tracing / locating missing healthcare records (Appendix 2). 7.9. Transportation of Records Healthcare records can only be removed from the main Trust site with prior agreement of the Health Records Manager or a supervisor in the absence of the Health Records Manager. Healthcare records should be transported where possible by the Healthcare Trust transport system via the Medical Records Department. Where this is not possible transportation and return date must be agreed with the Health Records Manager or their designated representative, following the guidelines in Appendix 3. Where it has been agreed that healthcare records are transported by a nominated member of staff, that staff member will become responsible for the security and confidentiality of those records in their care, until such time as they are returned to the Trust. The healthcare records must be held securely at all times. Private vehicles should never be left unattended while transporting healthcare records and no identifiable data should be visible. See Appendix 3 for full guidelines. 7.10. Loose paperwork Loose paperwork is not permitted within the folder. Staff must follow the filing instructions set out on the dividers within the case note folder. Detailed guidelines for filing within the folder are shown in Appendix 1. 7.11. Retention, Disposal and Destruction of Records The Trust follows national guidelines regarding the retention of healthcare records. A schedule detailing storage and destruction arrangements for healthcare records is shown at Appendix 4. A record of all files destroyed is kept in the Medical Records Department. 7.12. Electronic Documentation Management and Archiving The Electronic Documentation Management system refers to clinical records stored electronically once they have met the archiving criteria, negating the requirement to maintain a hard copy. NGH-PO-058 Page 15 of 46 Version No: 4 April 2014

Documentation which is held electronically and is viewable or completed by authorised users should not be hard copy printed and filed in the Healthcare Record. It is recognised that as Electronic Documentation becomes more widely available the overarching Patient Record will consist of clinical information that is either held on an IT system or within the paper record. Electronically held documentation does not need to be duplicated within the paper record with the only exception being the Discharge summary. 7.13. Access to Medical Records Patient Requests A dedicated team within medical records manages the provision of healthcare records and information in accordance with the Data Protection Act 1998, Access to Health Records Act 1990, Freedom of Information Act 2000 and the Information governance Toolkit. Further information is available in Appendix 6. 7.14. Advance Directives (Living Wills) It is the responsibility of the Health Records Manager to ensure that Advanced Directives are processed appropriately. The Trust has guidance on the creation and format of a Living Will (see Appendix 7) which should be followed. On receipt of a Living Will the alert box should be completed in the front cover of case note folder that the patient has an active Living Will. The Living Will should be clearly identifiable and be filed in a plastic pocket at the front of the notes with nothing further filed in front of it. 7.15. Standards of Record Keeping Generic record keeping standards define good practice for records and address the broad requirements that apply to all clinical record keeping. All staff have a personal responsibility to ensure the information they generate is legible, accurate, up to date and accessible. Staff must ensure they are aware of what they are recording and why. The quality of the information can have an impact on the quality of services, care and treatment the Trust provides. This data will be collected using the Healthcare Record Standards audit dataset (Appendix 8). 8. IMPLEMENTATION & TRAINING All new employees are to attend Trust induction training at the beginning of their NGH career which includes Information Governance and Healthcare Records Management. Further training linked to this policy is mandatory for some staff groups, further information about mandatory courses is contained in the Mandatory Training Policy (NGH-PO-306). All staff are to complete Information Governance training annually using the online training package or completing the Information Governance workbook. All staff required to use the ipm system will not be issued smartcards until completion of training. Medical Records offer further training to any member of staff that requires it on an adhoc basis for further details contact the Health Records Manager on EX 5307 NGH-PO-058 Page 16 of 46 Version No: 4 April 2014

9. MONITORING & REVIEW The Medical Record Team and clinical audit department will undertake two audits. The first will review the tracking process, loose filing and security of the Medical Record and data will be collected over a six month period (Appendix 9). The second will assess the quality of the record keeping standards and is collected monthly. The outcome of these audits will contribute as evidence of compliance against national standards required by the Care Quality Commission; Outcome 21, and the Information Governance Toolkit. Appendix 8 explains what is expected from all staff who document within the record. It is against these standards that the Trust will be audited as part of a monthly multi-disciplinary audit programme. The patients current record should be available at all times during their stay in hospital All records are legal documents; entries in the record will be in black ink Every page in the record should include the patient s name, identification number (MRN and NHS number), date of birth Every entry in the record should be dated, timed (24 hour clock), legible and signed by the person making the entry. This should be in real time and chronological order and be as close to the actual time as possible. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be corrected by a one-line strike through and be countersigned, dated and timed. The Clinical Audit Department will collate the audit results monthly and supply the findings to Information for publication by Speciality via the Clinical Outcomes Scorecard. The results from these audits will be presented to the Healthcare Records Group (HRG) quarterly. HRG will be responsible for ensuring that action plans are produced by the directorates to address where there are any gaps in compliance and will monitor completion of these action plans. Any risks to compliance will be reported to the Clinical Quality and Effectiveness Committee (CQEG), as part of the bi-annual reporting process and to the board via the Patient Safety, Clinical Quality and Governance Progress Report. Compliance with this policy is monitored through the Audit and Information Governance Departments, Health Records Group and Health Records Manager. Audits carried out will be reported to the Health Records Group with follow up action sanctioned. The Information Governance Department, Caldicott Guardian and Senior Information Risk Owner Support the NHS Information Governance Toolkit which is a mandated assessment of how the Trust deals with the various areas of information governance including healthcare records. Breaches of this policy will be managed in accordance with the Trust s Discipline and Performance Management Policies and could constitute Gross Misconduct if breaches are discovered. NGH-PO-058 Page 17 of 46 Version No: 4 April 2014

Minimum policy requirement to be monitored Process for monitoring Responsible individuals Frequency of monitorin g Responsible individual for development of action plan Responsible group for review of results / monitoring action plan Records are available when needed 1 Outpatients 2 Emergency admissions Audit of number of records available, spot checks & ipm tracking Health Record Manager Quarterly Health Record Manager Health Records Group 3 Elective admissions 4 Day cases CQC Standards Outcome 21A;D / IG toolkit 11-406 Records can be accessed & are secure CQC Standards Outcome 21 A;D Audit of tracking /loose filing / security Health Record Manager Quarterly Health Record Manager Health Records Group Records can be interpreted & trusted CQC standards Outcome 21 A, IG toolkit 11-401/404 Standards of Record Keeping Audit Care Group General Managers Monthly General / Service Managers Health Records Group Records can be maintained through time CQC standards Outcome 21 A Audit of scanning processes Health Record Manager / Archiving Supervisor Quarterly Health Record Manager / Archiving Supervisor Health Records Group Records are retained & disposed of appropriately CQC standards Outcome 21 B Audit of retention and disposal procedures Health Record Manager / Archiving Supervisor Quarterly Health Record Manager / Archiving Supervisor Health Records Group NGH-PO-058 Page 18 of 46 Version No: 4 April 2014

Staff are trained CQC standards Outcome 21 A;D Training log for all staff who have swipe access into the Medical Records Department Health Record Manager Quarterly Health Record Manager Health Records Group Records released under the 40 day requirement of the DPA IG toolkit 11-205/206 Number of records requested and released within 40 days Health Record Manager / Access Supervisor Quarterly Health Record Manager Health Records Group Complaints that require a response from Medical Records Number of complaints Health Record Manager / Complaints Manager Quarterly Health Record Manager Health Records Group incidents s that require a response from Medical Records Number of Datix s Health Record Manager / Governance Manager Quarterly Health Record Manager Health Records Group NGH-PO-058 Page 19 of 46 Version No: 4 April 2014

10. REFERENCES & ASSOCIATED DOCUMENTATION Care Quality Commission (2014) The essential standards. Available from http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/essential-standards [Accessed on 14 January 2014] Data Protection Act 1998. (c.29). London: HMSO Department of Health (2006) Records Management: NHS Code of Practice: part 1. [online]. London. Department of Health. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200138/records _Management_-_NHS_Code_of_Practice_Part_1.pdf [Accessed 14 January 2014] Department of Health (2006) Records Management: NHS Code of Practice: part 2. 2 nd ed. [online]. London. Department of Health. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200139/records _Management_-_NHS_Code_of_Practice_Part_2_second_edition.pdf [Accessed 14 January 2014] Department of Health (2013). NHS Constitution: the NHS belongs to all of us. [online]. London. Department of Health. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170656/nhs_co nstitution.pdf [Accessed 1 June 2013] Department of Health (2003) Confidentiality: NHS Code of Practice. [online]. London: DH. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200146/confi dentiality_-_nhs_code_of_practice.pdf [Accessed 17th February 2014] Department of Health, Social Services and Public Safety (2013) The Common Law Duty of Confidentiality. [online]. Available from: http://www.dhsspsni.gov.uk/gmgr-annexe-c8 [Accessed 17th February 2014]. Freedom of Information Act 2000. (c.36). London: HMSO Northampton General Hospital NHS Trust (2013) Equality and human Rights Strategy 2013-2016. Northampton: NGHT Northampton General Hospital NHS Trust (2011) Paper health record improvement strategy. NGH-SY-691 Northampton: NGHT Public Records Act 1958. (c. 51, 6 and 7 Eliz 2). London: HMSO NGH-PO-058 Page 20 of 46

Related NGH Policies NGH-PO-096 Freedom of Information NGH-PO-123 Information Lifecycle Policy (Corporate Records Management) NGH-PO-334 Data Protection and Confidentiality NGH-PT-575 Information Incident management Procedures NGH-PO-058 Page 21 of 46

APPENDICES Appendix 1 Guidelines for using the case note folder Folder Cover A bar-coded patient label MUST be affixed to the front and back of the patient file. This label should be kept up to date with correct details including NHS number, GP, postcode and bar code. N.B. An NHS number can be obtained by contacting the Data Quality team on X4911 or the Medical records Support Services Coordinator X113. The folder has a pre-printed Alert warning on the top right hand corner. Any Alerts are indicated inside the front cover by clinicians and transfer is arranged by Medical Records staff to new and subsequent volumes. If a microfilm is included in the folder, and/or electronically archived notes (scanned) are available, the appropriate box/boxes must be ticked. Nothing else should appear or be written on the folder cover. Inside the Folder The record will be mounted in its entirety on mediclips. These act as a flexible lever arch mechanism and enable the health record to be split and opened flat at any point to facilitate the writing of notes or the insertion of documents or extra sheets. Pocket inside front cover - should only house identification labels. No document should be left loose in the folder or thrust into this pocket. The record is divided into sections by the use of dividers with identifying tabs. Clear filing instructions then appear on each divider (form lists are guides and not exhaustive). Correspondence - letters and summaries Safeguarding Children/Adults For filing of Safeguarding Children/Adult notes Outpatient Clinical Record For filing clinical notes in the following order: NGV 1050 - Chronology of Events WZW 101 - Clinical (white) Record Sheet Individual records for the following specialties with identifying coloured strip: NGV 337 - Trauma and Orthopaedic (light blue) NGV 558 - Diabetes Centre (orange) NGH-PO-058 Page 22 of 46

NGV 359 NGV 204 NGV 045 - NGV 367 - ENT (green) Gynaecology (grey) Maxillofacial Unit (purple) Ophthalmology (yellow) Entries must be filed in chronological order - LATEST ENTRY AT THE BACK Inpatient Clinical Record For filing inpatient notes including: NGV 223 - Operation Sheet NGV 590 - Adult Non-elective Admission Proforma NGV 903 - Consent Form WZQ 552 - Per-Operative Care Pathway Operation Note (lilac sheet) Anaesthetics For filing anaesthetic records including: WZW 052 Anaesthetic Record Prescription Records For filing prescription records including: NGV 836 Adult Prescription & Administration Record NGV 1424 Adult Insulin Prescription & Diabetic Chart Allied Health Records For filing allied health notes including: WZV 489 Physiotherapy Dept. Referral & Treatment Investigations For filing investigation reports and results including: Haematology - pink Microbiology - dark blue Biochemistry - green X-ray - black (NB later folders have an X-Ray divider rather than a mount sheet Reports are mounted from the bottom upwards in date order. Other irregular or A4 reports e.g. histology, audiograms, cardiology, endoscopy, should be hole-punched and also filed in this section. Nursing Records: Assessments & Evaluations For filing nursing assessments, care plans and evaluations and integrated care pathways including: NGV 242 Trust Core Patient Handling Assessment & Care Plan NGH-PO-058 Page 23 of 46

NGV 299 Evaluation Form NGV 373 Trust Core Transfusion Care Plan NGV 541 Trust Falls Assessment & Core care Plan (Adult) NGV 736 Trust Patient Pain Assessment Tool & Core Care Plan NGV 941 Trust Core Nutritional Screening Tool NGV 1049 Patient Care Plan Post operative Care NGV 1106 Patient Trust Core Care Plan Diarrhoea NGV 1176 Trust Peripheral Venous Cannula (PVC) Care Plan NGV 1286 Adult Inpatient Admission NGV 1358 Trust Pressure Ulcer Assessment & Core Care Plan NGV 1465 Trust Core Oral Hygiene (Adult) Assessment Tool & Care Plan NGV 1497 Patient Orientation Checklist NGV 1523 Bed Rails Assessment & Trust Core Care Plan NGH 1580 - Adult Discharge Form Nursing Records: Observation Charts For filing nursing observation charts including: NGV 285 NGV 308 Fit Chart Paediatric Pain & Observation Chart NGV 312 Adult Neurological Chart incorporating papillary response and limb movements NGV 1088 Adult Ward 24 hour Fluid Balance & Observation Chart NGV 1255 Paediatric Neurovascular Limb Assessment NGV 1349 Food Record Chart NGV 1380 - Neurovascular Limb Assessment Adults NGV 1453 Care Round Patient Record Sheet NGV 1495 Enhanced Care Record Falls Patient Record Sheet WZP 387 Paediatric Fluid Balance Chart WZP 538 Adult Ward Vital Signs Observation Record Oncology Dividers are inserted as required for filing oncology notes including: Grey Oncology Database System (OCDS) sheets Radiotherapy/Chemotherapy Consent Forms Maternity records Dividers are inserted as required at the back of the folder and include: Antenatal Record Birth Record Postnatal Record NGH-PO-058 Page 24 of 46

Microfilm Records - If applicable are held in a plastic pocket attached to the inner rear cover. General Information Maternity Records From April 1999 a patient s maternity record has been filed together with the general record. If there is a separate folder, it must be securely banded to the main folder. These two folders must not be separated. It is vital that a clinician has all the information contained in both records when he/she meets the patient. From 2005, the maternity record has been incorporated with all other records in one folder (see above). Loose Documentation All loose records must be hole-punched and filed in the correct section. Small or sensitive records e.g. traces, photographs or other smaller records should be placed in a string envelope which should be hole-punched and placed in the record. The outside of the envelope should detail contents. Note the Maternity Department have customised envelope specifically for CTG traces. Loose filing is prohibited in the case note folder, other than a clinical outcome sheet that is inserted in to the folder as the patient sees a clinician. Every effort should be made to ensure that loose documentation is filed in the Case note at the point of the documents creation. However, if the Case note is not available it should be requested from the last holding location and the documentation merged from a temporary folder on receipt. Documentation should always be secured within the patient record and not moved onto another location in a loose format. It is vital that when a patient has been discharged, the discharging Ward is responsible for ensuring that all paper based information relating to the inpatient episode is filed within the Main Case note folder. The case note, complete with current information and discharge summary should be then readied for collection by the Clinical Coding Department. Recovering and Additional Volumes On occasions where the folder cover becomes damaged or worn the contents of the case note folder should be transferred in to a new folder, but the volume number should remain the same. On occasions that the case notes have been microfilmed a new folder should be produced, any alerts added but again the volume number remains the same. On occasions where the case note folder becomes too thick (greater than two inches) then that volume should be closed and a new volume should be issued by or requested from the Medical Records Department. Volumes must not be separated, and the latest two volumes will be made available to the clinician unless otherwise requested. On occasions that the notes have been archived on to optical disk a new volume is produced. NGH-PO-058 Page 25 of 46

Making an Entry Release the mediclip to prevent tearing of documents. All entries should be legible and written in pen or biro. Print and sign your name, enter the date, time and your bleep number after each entry in a record. Use only unambiguous abbreviations. Do not erase or ink out an entry - score out an error with a single line and separately date, time and sign additional notes. After reading a microfilmed record replace it in the pocket provided. (Please read the Medical Records Standards for more comprehensive instructions). Tracking Healthcare records must be available at any time for both clinical and clerical staff when carrying out their duties. To achieve this, healthcare records should always be tracked electronically as they move from department to department using the ipm system. All wards and clinic receptions are issued scanners to track large volumes of notes and training is available for their use. Failure to track healthcare records correctly my result in the loss or misfile of the notes and lead to patient care being compromised or procedures cancelled along with several hours of time lost in trying to locate them. If a set of notes are tracked to an individual that individual is responsible for the whereabouts of them and their security, failure to control healthcare records that are in the care of an individual may result in disciplinary action or prosecution under this Policy and in serious instances the Data Protection Act 1998. All staff handling health records should always maintain the highest standards of confidentiality NGH-PO-058 Page 26 of 46

Appendix 2 Procedures for Tracing/Locating missing Healthcare Records This procedure will give guidance on how to locate healthcare records missing for inpatient or outpatient attendances and to record events in those cases when the patient healthcare record is not found. IT IS IMPORTANT TO use any available tracking facility in order to avoid unnecessary phone calls to secretaries/other departments. Check events on ipm in Patient Record Enquiry and Patient Transactions. The notes may also have been passed to another area without being tracked, or Medical Records being notified. Telephone those areas where the healthcare record has been tracked to, starting at the most recent. Remember the healthcare record may have had a note on to go back to another secretary or department. Check the pigeon holes as the notes may be on their way back to the original department and don t forget the clinic sheet as this may give an indication of where a folder was found for the previous clinic. Ask the secretary/department for information as to where they may have sent the healthcare record. If it is still tracked to them they must check again all healthcare records in their care. If the notes are tracked back to the filing room a basic misfile check should be undertaken (see separate instructions). Notify your Team Leader. You must tell your Team Leader or the Medical Records Supervisor that you are experiencing problems as soon as possible. Do not leave it until the patient is waiting in clinic. In the case of Inpatients, your Team Leader must be notified immediately. The Team Leaders/Medical Records Supervisor should start again following the above procedure. However if the notes are tracked back to main filing room an in-depth misfile check must be undertaken. If the patient healthcare record is tracked out a physical check of that area should be undertaken. A Missing Notes Flyer may be distributed to all staff in the Trust if the above procedure is unsuccessful A patient should not be seen at clinic or as an inpatient without sight of the healthcare record without the agreement of the Health Records Manager. If this is agreed a Clinical Risk form must be completed by the Team Leader or Supervisor with a copy to the Directorate Manager. An interim tracer should be issued, informing staff that if the patient s notes come back into main filing room they must notify the Medical Records Supervisor or leave the healthcare record on their desk. Clinical Risk forms should be marked accordingly when the healthcare record comes back to the filing room or is located. In the case of inpatients a clinical risk form should be completed even if the healthcare record is located whilst the patient is still on the ward. NGH-PO-058 Page 27 of 46

At regular intervals a notice will be circulated to all areas listing any healthcare records still not returned to Medical Records and requesting they check all healthcare records held by them. Out of Hours: In the case of missing notes, Out of Hours Medical Records staff assumes the role of the Team Leader. Follow the above procedures for tracing the notes appropriate to you. All healthcare records not located during your shift must be entered into the out of hours missing book, ready for the next shift to take over the search. Please give the following details: Time of request and by who i.e. ward, A&E etc. List exactly which offices you have searched and make any suggestions of where to continue the search. Give details of any misfile check carried out. If the notes are tracked back to records this must be done. Before leaving the department to look for notes remember to check information on ipm, in clinic prep and the pigeon holes - this may prevent a wasted search. Remember a patient s notes must be found for his/her attendance. It may pose a clinical risk if a consultant does not have all health details to hand when he/she sees a patient. It is the duty of EVERY member of staff who handles healthcare records to take responsibility for it while it is in his/her care and to know exactly what she/he has done with it when it is no longer required. NGH-PO-058 Page 28 of 46

Medical Records Missing Form Please write clearly and concisely Patient Name (Surname in CAPS first) Hospital Number Request Date: Name of Clinic Dept or Ward Time of Appointment Name of Person Completing Form: Last Tracked To: Date and Time Tracked: NB. If tracked to filing room before 6/12/12 please ask Avril or Steffan as they may be off-site Details of all areas contacted during the day(s) and details of searches undertaken within or outside of the department: Out of Hours please search in the following areas: Please pick up on requests still outstanding at the start of the shift. Please complete the next section even if no further searches are undertaken, until notes are located. Please log if an internal incident is completed and staple to this form. Please log when flyer is distributed. NGH-PO-058 Page 29 of 46

Staff Name/Date Where searched: Found: Yes/No Location Time Taken to Search Delivered Yes/No Staff Name/Date Where searched: Found: Yes/No Location Time Taken to Search Delivered Yes/No Staff Name/Date Where searched: Found: Yes/No Location Time Taken to Search Delivered Yes/No Staff Name/Date Where searched: Found: Yes/No Location Time Taken to Search Delivered Yes/No Please fill in this form when looking for missing notes and take care to record time taken when searching. NGH-PO-058 Page 30 of 46

Appendix 3 Guidance in maintaining the security and safety of NGH notes offsite Given the current diverse locations for service delivery and our record systems, there will be times when medical records leave NGH premises. It is in the best interests of patients that their records are available at consultations, and a certain amount of home working is likely to continue. This document aims to highlight and define strategies to reduce the potential for breaches in security and confidentiality inherent in this practice. The removal of notes occurs with the understanding that return will be prompt if they are needed in the hospital and that the development of an additional reliable tracking mechanism is required. This document forms part of the Medical Records Policy. The person removing notes remains responsible at all times for the safe storage of them and their return to the hospital site immediately if requested. Security and Storage Remove notes only if strictly necessary for patient care and for the minimum amount of time. Provide a covered rigid container for the notes crate or pilot case. This will provide the minimal physical damage to the notes and cover identifiable labels if car is an estate without a boot. Transport in the boot of the car and bring into your house overnight. Do not leave in open view in your house. Personnel that are required to take notes home must store them in a locked, nonportable cabinet, safe or container. For consented research or case presentation consider taking photocopies of the relevant sections instead of removing the entire set of notes, and shred these copies or return them to Medical Records to be destroyed immediately after use. Track the notes. Medical Records electronically track notes to regular off-site clinics. The consultant secretary should be made aware of any notes taken off-site by the consultant or junior staff. A record of these must be kept by the secretary, and a contact number must be available to Medical records staff should the notes be required in an emergency. It is the responsibility of the borrower to return the notes to NGH immediately. GP Surgery storage If NGH Case-notes are stored in a GP Surgery they must be stored safely and securely. If photocopies of notes are taken off-site they must be confidentially destroyed on return Health care records may ONLY be taken offsite for direct patient care. They are not to be taken for research or any other purpose. Breaches of this policy will be managed in accordance with the Trust s Discipline and Performance Management Policies and could constitute Gross Misconduct if breaches are discovered. NGH-PO-058 Page 31 of 46

Appendix 4 Preservation, Destruction, Microfilming, Scanning, and Off-site Storage of Health Records This policy seeks to formalise arrangements for the efficient management of the Health Records Library and any subsidiary libraries through the agreement and implementation of preservation, destruction, microfilming, scanning and offsite storage procedures which are in accordance with current legislation. Confidential waste is collected and confidentially destroyed off-site by an approved contractor a company with whom the trust has a contract. While the main patient folder is filed in the central Health Records Library during treatment and up to 2 years after that treatment, other subsidiary components of the patient record may be filed electronically or physically elsewhere. However the whole remains the legal responsibility of the Health Records Manager. Implementation of the policy on behalf of the Trust will be managed by Medical Records staff, according to strict departmental guidelines, and any proposed destruction, reformatting or relocation of health records should be discussed with and agreed by the Health Records Manager in the first instance. GENERAL HEALTH RECORDS Primary documents within an adult general health record comprising correspondence and clinical history should be retained in hardcopy on microfiche or document imaging system for not less than 20 years following conclusion of treatment. Nursing notes will be stored until 8 years after discharge and then destroyed. General health records relating to children should be retained for not less than 25 years following conclusion of treatment. However nursing records may be culled and microfilmed/scanned after discharge. Paediatric records may be further culled and microfilmed/scanned prior to conclusion of treatment at the request of the consultant. OBSTETRIC folders should be retained in hardcopy form or on microfiche/scanned for not less than 25 years following the last contact. ONCOLOGY records should be retained indefinitely. HAEMATOLOGY stem cell transplant records should be retained for 30 years minimum, and the UHL-LRI stem cell laboratory contacted prior to discard since records must be kept for a minimum of 30 years after the death of the patient or the destruction/use of cryopreserved stem cells (whichever is the later) Human Tissue Act 2004. DECEASED patient records should be retained for 8 years after the date of death. RESEARCH AND DEVELOPMENT DECEASED PATIENT records are retained for 15 years after death or the end of the trial. OPERATION LEDGERS and A&E REGISTERS should be retained indefinitely. A&E RECORDS. A&E, ENT and EYE CASUALTY records should be retained for 8 years with the exception of those for children, which will be kept until the child is 25 years old, or 8 years after death. NGH-PO-058 Page 32 of 46

ANCILLARY CLINICAL DOCUMENTS e.g. ITU treatment charts, will be retained for 8 years, with the exception of those for children, which will be kept until the child is 25 years old or 8 years after death. MENTAL HEALTH records relating to mentally disordered persons within the meaning of Mental Health Act 1983 should be retained for 20 years from the date at which, in the opinion of the doctor concerned, the disorder has ceased or diminished to the point where no further care or treatment is considered necessary. MICROFILMING / SCANNING Adult records may be scanned 2 years after last contact with the hospital. In addition, when a patient record becomes too large, documentation may be culled and scanned, leaving at least 2 years information in hard copy. Nursing notes may be culled and scanned immediately following discharge. Children s records may be scanned 5 years after last contact with the hospital. In addition, when a patient record becomes too large, documentation may be culled and scanned, leaving at least 5 years information in hard copy. Maternity records may be scanned 5 years after the latest birth. Notes for previous births may be culled and scanned. The hard copy of the record will be destroyed following quality checks. If filmed, a microfiche copy of individual records will be filed in the main library in readiness for reactivating of the patient record and a second copy retained on reel within the Archiving Unit. Scanned images will be retained on the system for the appropriate length of time (please see above). Exceptions: If a member of the Consultant staff is of the opinion that a record should be preserved in its original form past the number of years stipulated in this policy for sound clinical reasons or future scientific or public health interest, he/she should notify the Health Records Manager in writing so that appropriate alert labels may be placed on the folder. Similarly if a legal representative of the hospital wishes to preserve a record in its original form until the expiry date for any possible litigation, he/she should also notify the Health Records Manager in writing so that the record may be labelled appropriately. OFF SITE ARCHIVE STORAGE OF HEALTH RECORDS Some archived records may be stored off site by an approved contractor, an archiving company with whom Northampton General Hospital has a data management contract. Any request for separate or individual records to be stored offsite must be agreed by the Medical Records Group and co-coordinated through the Archiving Supervisor. Deceased patient records are kept in the Archiving Department for up to two years and then sent to offsite storage. They will be confidentially destroyed 8 years after death. NGH-PO-058 Page 33 of 46

Health records of deceased patients undergoing clinical trials will be kept for 15 years after commencement of the trial or 8 years after death whichever is the longer, and then confidentially destroyed. General nursing records will be destroyed 8 years after discharge for each episode. The following records are stored off site but coordinated and financed by the relevant department: Oncology records for deceased patients. These should not be destroyed. Research and Development records.. COUNTY RECORDS OFFICE - WOOTTON HALL The County Archivist stores various maternity, ward and theatre ledgers. There is a comprehensive list held in the Medical Records Department. These are retained for permanent preservation. NGH-PO-058 Page 34 of 46

Appendix 5 Archiving of Healthcare Records and Electronic Healthcare Records Archiving Policy to follow when ratified. NGH-PO-058 Page 35 of 46

Appendix 6 Access to Medical Records; Patient Requests Responding to Patients requests for what happens to their information and how they can access their records. If questioned by a patient about access to healthcare records refer them to the leaflet Health Records-Your Rights. This leaflet contains information about why we keep healthcare records along with how to gain access to them. Access to any healthcare records has to be made in writing and a charge of up to 50 may be made. Requests may be sent to the following address: Health Records Manager Northampton General Hospital NHS Trust Cliftonville Northampton NN1 5BD Patients should not be directed direct to Medical records for access or complaints, PALS should be used to deal with patient enquiries. No staff are permitted to access their own health record or other family members records through the Trust IT systems or confidential paperwork. Access should be made by writing to Medical Records via the Trust Subject Access procedures, even if a family member says they give their consent. Breaches of this requirement will be managed under the DP Policy and Trusts Disciplinary Policy. The Data Protection Act 1991 provides good reason why staff should only access records through the Subject Access request process, namely there is a requirement for the Trust not to disclose third party information which may be held in the record when someone is exercising their right of access. Also within the Department of Health guidance for Access to Health Records Requests 2010 it mentions the Data Protection (subject Access Modification) (Health) Order 2000 which sets out the appropriate health professional to be consulted to assist with subject access requests, which can withhold information from a patient if they believe to release the information would lead to harm or distress to the patient. It is quite reasonable and understandable for patients to want to know what happens to their information and to want reassurance that the Trust will take all reasonable steps to secure their confidential data. All staff on reception points for all Hospital services dealing with patients or their representatives must be trained to respond to questions on how they access their health record and what happens to their information. All staff should refer patients with questions about their information, to posters and leaflets that give detailed information about what happens to patients information and why. Leaflets available are Your Health Record Protecting your information and Accessing your Health Record NGH-PO-058 Page 36 of 46

If the patient or person with the enquiry still requires further information, then they should be referred to a senior manager if available, to re-assure and answer any questions. For further queries about happens to patients Information; the person should be referred directly to the Trusts Information Governance Manager who will be able to provide detailed information as required. Patients have the legal right to access their records; this will be processed in accordance with the requirements outlined within the Data Protection Act. Any requests for access to patients Health Records should be forwarded to the Medical Records Department. Patient records can be disclosed to other organisations involved in the patient care and treatment in line with an Information Sharing Agreement that is in place across the local health community. Disclosure of Health Record Information to the Police, Solicitors, patients/clients, family members and staff is governed by strict guidelines and legislation. There are also guidelines for requests to access records of deceased patients. Should staff have a query about the disclosure of any aspect of a patient s record, then they are encouraged to make contact with the Trusts Medical Records manager/information Governance Manager. Any request for business/corporate information under the Freedom of Information Act should be directed to the Trusts Information Governance Manager before disclosure takes place. For Further details consult the Trusts Data Protection and Information Governance policies. NGH-PO-058 Page 37 of 46

Appendix 7 Living wills / advanced directives Introduction An advance Directive / Living Will is a clear instruction refusing some or all, of a medical procedure and maybe be made by a competent adult. It should be in written form with the intention that it will apply at some future and will give directions in respect of future health care. In accordance with the BMA code of Practice 1995 guidance was given to health professionals about the drafting and implementation of advanced statements to include: Guidelines in Drafting / Responsibility on writing an advance directive Patient The Code points out that advance statements should not be made under pressure. An advance statement must be made while the patient is mentally competent. Advanced statements should be in written form using clear and unambiguous language, and as a minimum, that the following information is included. a) Full name b) Address c) Name and address of General Practitioner d) Whether advice was sought from health professionals e) Signature f) Date drafted and reviewed g) Witness signature h) A clear statement of wishes, either general or specific i) The name, address and telephone number of your nominated person, if you have one. The code specifies that the storage of an advanced statement and notification of its existence is primarily the responsibility of the individual Patients should remember to review their statements on a regular basis It is the responsibility of the patient to notify us in writing of any changes The code suggests that the patient also gives a copy to any additional treating hospitals and their GP and is responsible for notifying them in writing of any changes. Signing off at the end with I understand the statement above and agree to abide by the guidelines laid down in accordance with the BMA code of practice 1995, or something similar Name (print) Hospital Registration Number Signature NGH-PO-058 Page 38 of 46

Appendix 8 Healthcare Record Standards Audit 2014 modified question-set Please randomly select 10 sets of notes currently on the ward/department. For this audit place either a tick for yes or a cross X for no or state N/A if not applicable. Record being audited Medical Nursing OT Physio Date Ward Q.1 Does the front page of every sheet contain an addressograph label? If yes go to Q.5 [3] If no go to Q.2 Q.2 NO addressograph - does the page contain patient s Full Name? [1] Q.3 NO addressograph - does the page contain date of Birth? [1] Q.4 NO addressograph - does the page contain hospital Number or NHS number? [1] Q.5 Is date recorded for each entry? [1] Q.6 Is time recorded for each entry? [1] Q.7 Is there a signature of the person making the entry? [1] Q.8 Is the surname written clearly? [1] Q.9 Is the staff designation recorded? [1] Q.10 Are there any alterations / deletions? If yes, go to Q.11 If no, go to Q.15 [4] Q.11 Alteration/deletion - is there a scored line through it [1] Q.12 Alteration/deletion - is there a signature recorded next to it [1] Q.13 Alteration/deletion is there a date recorded next to it [1] Q.14 Alteration/deletion - is there a time recorded next to it [1] Q.15 Can you read this medical record with ease? [1] Q.16 Is record Contemporaneous i.e. written in chronological order and within 24 hours of care event? [1] Q.17 Are there any loose sheets in the Healthcare record NGH-PO-058 Page 39 of 46

Appendix 9 Medical Records internal record audit The purpose of this audit is to assess departments in regard to the standards of holding health care records, including security, tracking and filing. Department/Ward Date Patient Filing Test Tracking Security Remarks General Notes: Name of Assessor. NGH-PO-058 Page 40 of 46

Appendix 10 Business continuity, emergency & major incident policy and ipm downtime Healthcare records are an essential tool for clinicians and have to be easily accessible at all times. Due to the majority of healthcare records being in paper form they are at risk to fire and flood. In the event of a fire Medical Records staff will react in accordance with local procedures. Major incidents could be in the form of an emergency within Medical Records, a large scale accident or event in the Trust or surrounding area or loss of electronic systems in the Trust such as ipm. Evacuation of Medical Records In the event of a fire in Medical Records, on discovering the fire or hearing the fire alarm Medical Records staff will evacuate to a predefined area with the following personnel carrying out: Health Records Manager and Archive Supervisor Sweep of area and last people out with recall folder Medical Records Supervisor Cabin keys, Evacuation/Emergency Box RIP Clerk Secure the Archiving Department Access Supervisor Secure Access Office Fire Wardens Fire warden check list When all personnel are accounted for the Health records Manager will relocate in Cancer Services with the Head of Cancer and Medical Records EXT 5945. If the weather is inclement once accounted for Medical Records staff will relocate to a suitable location (Cripps) until the all clear is given. If the fire is in Medical Records then: The admissions clerk will relocate to A&E along with the Medical Records Supervisor and Service Support Coordinator. The RIP Clerk will relocate to Clinical Coding The Archive Supervisor will remain accountable for the rest of the staff and relocate to a suitable location (Cripps) MAJOR INCIDENT OR EPIDEMIC PLAN FOR MEDICAL RECORDS The Health Records Manger HRM, is responsible for initiating the Major Incident or Epidemic Plan for Medical Records and reviewing the plan annually. Medical Records Supervisors along with the HRM form the Management Team for Medical Records NGH-PO-058 Page 41 of 46

Aims and objectives of the Major Incident or Epidemic plan The aim of this plan is to enable staff to respond in an effective and quick way to a major incident or health crisis that may hit NGH, Northampton or the surrounding area. Examples of this could be fire or flood in Medical records, large explosions, large scale road traffic accidents, epidemics or terrorist activity in the area. The objectives are: To have clear, unambiguous actions for staff to follow; To have a person in charge of the incident; For staff to be trained in the correct procedures to be followed. Major Incident management Main duties are: To provide NGH and surrounding trusts quick access to health records in the event of a major incident. To provide NGH with adequate personnel to carryout core business in the event of a major incident. To provide training for all staff to cope with a major incident. A full breakdown of roles and responsibilities for Medical Records staff is held by the Health records Manager. ipm Downtime This will be added when there is an electronic alternative. NGH-PO-058 Page 42 of 46

Appendix 11 Contact details for medical records staff Head of Cancer Services and Medical Records 5945 Health Records Manger 5307 Medical Records Supervisor 5504 Access Supervisor 5565 Access Team 5279 / 3904 / 5505 Archiving Supervisor 5278 RIP Clerk 5276 Services Support Coordinator 5113 Admissions & Emergencies Clerk 5502 Area 2 5515 4568 3706 5742 4224 3709 5501 4715 Area 3 5499 5499 5317 3967 4646 5206 3708 5503 Area 4 5498 3903 4560 4954 4456 4222 4956 4223 Details accurate November 2013 NGH-PO-058 Page 43 of 46

Appendix 12 Health records management Bi-annual Report to CQEG proforma INDICATOR Availability of case-notes: 1. Outpatients 2. Emergency admissions 3. Elective admissions 4. Day cases REPORT Outcome 21A;D / IG toolkit 11-406 Percentage of records released under the 40 day requirement of the Data Protection Act 1998 IG toolkit 11-205/206 Number of formal complaints that require a response from the Medical Record Department Number of Datix s involving health records Audits undertaken during the quarter:- 1. Clinical audit of healthcare record standards IG toolkit 11-401/404 2. Audit of tracking, security & filing Outcome 21 A;D Number of staff trained to access Medical Records Outcome 21 A;D Adverse incidents involving records:- 1. Reported breaches of security 2. Reported breaches of confidentiality 3. Cancelled OPAs / procedures Outcome 21 A;D Vacancy factor in medical records Scheduled destruction of records undertaken during the six-months Outcome 21 B NGH-PO-058 Page 44 of 46

Appendix 13 Terms of Reference Healthcare Records Group, Version 2 Definition: The Healthcare Records Group is responsible for providing assurance to the Clinical Quality & Effectiveness Group that Records Management meets the CQC Outcome 21 and the Information Governance Toolkit. Trust Healthcare Records Group Purpose of Committee To inform staff of the Trust requirements in relation to records management and what is expected of them. To protect the Trust as an employer and ensure that we comply with the relevant legislation and codes of practice. To raise the profile of records management in the organisation. Functions Healthcare Records Process To monitor the health Records Service to ensure that the overall objectives of the Trust are met and that the Trust complies with professional good practice, current legislation, national policies and guidelines. To develop policies and procedures relating to the health records Service, regularly review those policies and amend them as appropriate and ensure that all staff are aware of the policies and procedures and that appropriate training is given. To oversee, evaluate and monitor health records documentation including case-note architecture and documentation for inclusion in the case-notes. Standard of the Healthcare Records To develop, implement and regularly monitor standards of the Healthcare Record and ensure that compliance with the standards is reported to the Clinical Quality and Effectiveness Group. To ensure that Health Records audits are implemented on a regular, systematic basis. Development of the Electronic Healthcare Record Trust-wide To encourage and monitor the development of multi-disciplinary records in order to support the development and use of the Electronic Health Record. Membership Chair Director of Strategy & Partnerships Deputy Chair Consultant NGH-PO-058 Page 45 of 46

Clinical Representation Consultant Consultant Patient Safety Lead Practice Development Nurse Non Clinical Representation Head of Cancer & Medical Records Health Records Manager Deputy Director of ICT Clinical Safety Effectiveness & Audit Lead Information Governance Lead Clinical Coding Manager Ward Clerk It is expected that these members will attend each meeting. Should any member fail to attend, or send a deputy, on two consecutive occasions the Chair of the Group will write to the member to request attendance. In addition other staff will be invited to attend the Committee meetings as and when required. In attendance Reporting arrangements The Group will report to CQEG on a bi-annual basis Distribution of notes Minutes will be distributed to the above group within a week of the Healthcare Records Group meeting Frequency of Meeting The Committee will meet quarterly Quorum The Healthcare records Group will be considered quorate when there are at least 6 members present including the following: Chair or deputy chair X2 Clinical representatives X3 Non-clinical representatives NGH-PO-058 Page 46 of 46

Health Records Management #NGH-PO-058 Business Area Planning & Development Person Responsible Created Last Review 16th June, 2010 1st April, 2013 Status Complete Next Review n/a Screening Data Name, job title, department and telephone number of the person completing this Equality Impact Assessment Sue Cross, Governance Ext 3439 on behalf of Tracey Harris What is the title and number of this policy/procedure/guideline? Health Records Management Policy, NGH-PO-058 What are the main aims, objectives or purpose of this policy/procedure/guideline? This policy defines the structure and processes necessary for the management of Trust clinical records in all media through control of content, storage, transportation and access in order to ensure a high standard of care. It also sets out the way in which the Trust will meet its legal obligations in relation to the Data Protection Act 1998, Freedom of Information Act 2000 and standards set by the Care Quality Commission and the NHSLA in respect of records management. Who is intended to benefit from this policy/procedure/guideline? This policy is applicable to all Trust staff who handle, use, and/or access health records of all types in both an acute or community setting. Is this a Trustwide, Directorate only or Department only policy/procedure/guideline? Trustwide Who is responsible for the implementation of the policy/procedure/guideline? Health Records Manager What data are available to facilitate the screening of this policy? See Policy Is there any evidence of higher or lower participation, uptake or exclusion, by the following characteristics? In the context of the preceding sections are there any relevant groups which you believe should be consulted? Please specify and give reasons: What data are required in the future to ensure effective monitoring?

See Policy section 9 Considering all information above please indicate areas where a differential impact occurs or has the potential to occur. Any other comments on the policy This policy is equal to all Potential for differential impact? None Recommend this EA for Full Impact Analysis? No Comments This policy requires no detailed EQIA as policy is equal to all Rate this EA Low Organisation Sign-off Data If the policy is implemented what is the potential risk of it having an adverse effect on equality? Low Risk - probably will not have an adverse effect on equality If the policy is implemented what is the potential of it having a positive effect on equality and relations? Low Potential - probably will not promote equality or good relations If the potential for risk or positive effect occurred what would be the potential number of people it effected? A low number of people would be affected Based on the answers to questions 1-3 will this policy promote equality and diversity? No By following the procedure it will ensure that patients and service users recieve an equitable service regarding their health records Do you have any additional comments or observations about the policy? How will the results of the Equality Impact Assessment will be published? On the intranet, with a summary on the Trusts website Have you completed any Action Boxes with recommended actions or changes for completion?

No If 'Yes' please print off an action plan report along with a copy of the Equality Impact Assessment report to the policy/procedure/guidelines owner, and record below who it has been sent to If 'No' please print off a copy of the Equality Impact Assessment report to the policy/procedure/guidelines owner, and record below who it has been sent to Health Records Manager Please give details of the monitoring arrangements See section 8 of policy Monitoring arrangements Equal to all therefore no implications Outstanding Actions No outstanding actions

FORM 1 & 2 - To be completed by document lead FORM 1a- RATIFICATION FORM - FOR COMPLETION BY DOCUMENT LEAD Note: Delegated ratification groups may use alternative ratification documents approved by the procedural document groups. DOCUMENT DETAILS Document Name: NGH-PO-058 Is the document new? No If yes a new number will be allocated by Governance N/A If No - quote old Document Reference Number N/A This Version Number: Version: 4 Date originally ratified: September 2007 Date reviewed: January 2014 Date of next review: a 3 year date will be given unless you January 2016 (2 Years) specify different If a Policy has the document been No Equality & Diversity Impact Assessed? (please attach the electronic copy) DETAILS OF NOMINATED LEAD Full Name: Liz Gill Job Title: Interim Dcase Lead Directorate: Medical Directors Office Email Address: elizabeth.gill@ngh.nhs.uk Ext No: 7792 DOCUMENT IDENTIFICATION Keywords: please give up to 10 to assist a search on intranet Healthcare, Record, Tracking, Archive, Retention, Record lifecycle, Storage GROUPS WHO THIS DOCUMENT WILL AFFECT? ( please highlight the Directorates below who will need to take note of this updated / new policy ) Anaesthetics & Critical Care Gynaecology Medicine Child Health Haematology Nursing & Patient Services Corporate Affairs Head & Neck - inc Ophthalmology Obstetrics Diagnostics Human Resources Oncology Facilities Infection Control Planning & Development Finance Information Governance Trauma & Orthopaedics General Surgery Trust wide TO BE DISSEMINATED TO: NB if Trust wide document it should be electronically disseminated to Head Nurses/ Dm s and CD s.list below all additional ways you as document lead intend to implement this policy such as; as presentations at groups, forums, meetings, workshops, The Point, Insight, newsletters, training etc below: Where When Who Induction training Monthly Craig Smith Health Records Manager NGH-PO-001 Version 7.2 Appendix 4.1 Page 1 of 2

FORM 1 & 2 - To be completed by document lead FORM 2 - RATIFICATION FORM to be completed by the document lead Please Note: Document will not be uploaded onto the intranet without completion of this form CONSULTATION PROCESS NB: You MUST request and record a response from those you consult, even if their response requires no changes. Consider Relevant staff groups that the document affects/ will be used by, Directorate Managers, Head of Department,CDs, Head Name, Committee or Group Consulted Nurses, NGH library regarding References made, Staff Side (Unions), HR Others please specify Date Policy Sent Amendments requested? Amendments Made - for Consultation Comments Care Group Management March 2014 No Clinical Directors March 2014 No Consultants March 2014 No General Managers March 2014 No Governance March 2014 No Heads of Department March 2014 No Modern Matrons March 2014 No Service Managers March 2014 No Ward Sisters March 2014 No Existing document only - FOR COMPLETION BY DOCUMENT LEAD Have there been any significant changes to this document? YES if no you do not need to complete a consultation process Sections Amended: YES / NO Specific area amended within this section Re-formatted into current Trust format YES Summary/ Introduction/Purpose YES Scope YES Definitions NO Roles and responsibilities YES Substantive content YES Monitoring YES Refs & Assoc Docs YES Appendices YES NGH-PO-001 Version 7.2 Appendix 4.1 Page 2 of 2

FORM 3- RATIFICATION FORM (FOR PROCEDURAL DOCUMENTS GROUP USE ONLY) Read in conjunction with FORM 2 Document Health Records Management NGH-PO-058 Document Name: No: Overall Comments from PDG re Tidy and add in appendices, update version control, send out for full consultation the Policy to go for Chair Approval (subject to feedback from consultation) Consultation Do you feel that a reasonable attempt has been made to ensure relevant expertise has been used? Title -Is the title clear and unambiguous? Is it clear whether the document is a strategy, policy, protocol, guideline or standard? Summary Is it brief and to the point? Introduction Is it brief and to the point? Purpose Is the purpose for the development of the document clearly stated? Scope -Is the target audience clear and unambiguous? Compliance statements is it the latest version Definitions is it clear what definitions have been used in the Roles & Responsibilities Do the individuals listed understand about their role in managing and implementing the policy? Substantive Content is the Information presented clear/concise and sufficient? Implementation & Training is it clear how this will procedural document will be implemented and what training is required? Monitoring & Review (policy only) -Are you satisfied that the information given will in fact monitor compliance with the policy? References & Associated Documentation / Appendicesare these up to date and in Harvard Does the information provided provide a clear evidence base? Are the reference provided using Harvard Referencing format? Are the keywords relevant YES / NO / NA Recommendations Recommendations completed NO A full consultation is needed for this Please can the track changes be agreed and then I will send document to include all staff out Trustwide for consultation? members who have roles within it YES YES YES YES YES YES YES YES YES / NO / NA YES YES YES YES / NO / NA Yes/No/ Add in Siro All Trust employees add in - dealing with medical records in a safe and responsible of all Minor amendment see track changes Add in all appendices are reference within the document, place in right order Offsite archive storage is this still needed? (see Track changes Chris Pallot is our SIRO and was already documented in the policy. Added section about employees Amended Apologies, all appendicies now in policy Name of Ratification Ratified Yes: Date of Meeting: Group Ratified No: Ratified subject to amendments and chair approval 26/02/2014 Chair Approved Ratified Yes: Date of Meeting: 01/04/2014 Taken from NGH-PO-001 Version 7.2 Appendix 4.2.2 (last updated June 2012) Page 1 of 1