Records Management Policy Document Number SOP2006-073 File No. 07/7 Date issued 1 September 2006 Author Branch Records and Mail Services Unit Branch contact 9320.7722 Division Finance & Data Services Summary The purpose of this policy is to outline the Ambulance Service of NSW s records management policy. Applies to All Ambulance Service of NSW staff All Operational Staff All Administration staff All Headquarters staff Division staff (select Aero medical, Northern, Southern, Sydney, Western) Operations Centres (select All, Aero medical, Northern, Southern, Sydney, Western) Review date 1 September 2008 Previous reference Status Active Approved by Chief Executive Compliance with this policy directive is mandatory. Space Page 1 of 17
RECORDS MANAGEMENT POLICY 1. Preamble 1.1 Introduction This policy outlines a system for effective information and records management at the Ambulance Service of NSW. The introduction of a Records Management system provides the Service with the opportunity to organise and use corporate knowledge state-wide for greater organisational effectiveness and to meet its statutory obligations in relation to record keeping. The objective of the Records Management system is to provide a common, shared source of information which is accessible, within security restrictions, to everyone who needs it, for as long as it is needed. 1.2 Purpose The aim of this document is to establish sound records management based on the State Records Act 1998 and standards of best practice. The procedures documented in this policy and articulated through the Records Management program establish a consistent approach to the management of records in many forms including: Paper records Email Faxes Voicemail Electronic records Legal advice Technical reports Forms Technical information Film and video Audio recordings Web and multimedia products Photographs Publications Page 2 of 17
1.3 Scope In Scope The records system aims to cover administrative, business and operational records created in all offices of the Ambulance Service by staff in the course of their duties. The principles and standards described by this policy holistically apply to all records regardless of format or purpose. Out of Scope Records that contribute towards the treatment of patients (e.g. Patient Health Care Records) are outside the range of this policy. Although these records fall within the requirements of the State Records Act 1998 they are addressed separately through other documents such as the Patient Health Care Record Guidelines and Instructional Circulars. 2. Statement of Policy Good record keeping is essential for effective and efficient business. To facilitate this, the policy of the Ambulance Service of NSW is that: All staff are responsible for creating and maintaining full and accurate records of the Service s business Record keeping practices across the Service are to be consistent with this policy Management staff are responsible for implementing and ensuring sound records management practices are adopted within their administrative units Electronic records are to be managed as an integral and routine part of administrative activity Dispersed and private collections of records are to be integrated into a unified information base as part of the corporate memory Records created in the course of normal administrative duties are public records and may not be removed from the Service s custody without the authorisation of the Records Coordinator. Records required by solicitors should be copies, with the originals retained by the Service. Disposal of records is managed by the Records Coordinator in accordance with the NSW State Records Authority authorised disposal authorities Page 3 of 17
3. Standards 3.1 Legislative Standards and Regulatory Environment The Ambulance Service as a NSW agency comes under the NSW State Records Act 1998, which outlines the responsibilities of the Service and makes mandatory compliance with standards and policies issued by the State Records Authority. These standards are in accordance with international standard ISO 15489. Legislation as it applies to evidence, litigation, occupational health and safety and health care are particularly important to the Ambulance Service to protect its rights and employees. Legislation with significant record keeping requirements includes: Administrative Laws Freedom of Information Act 1989 Evidence Act 1995 Privacy and Personal Information Protection Act 1998 Health Records and Information Privacy Act 2002 Industrial Relations Act 1991 Public Finance and Audit Act 1983 Independent Commission Against Corruption 1988 Charitable Fundraising Act 1991 Crimes Act 1900 Ombudsman Act 1974 Limitations Act 1969 Anti Discrimination Act 1977 Civil Liability Act Government and Related Employees Appeal Tribunal Act 1980 Employee-Management Laws Occupational Health and Safety Act 2000 Workers Compensation Act 1987 Workplace Injury Management and Workers Compensation Act 2001 Protected Disclosures Act 1994 Child Protection (Prohibited Employment) Act 1998 Ombudsman Act 1974 Page 4 of 17
Health Care Laws Health Care Complaints Act 1993 Health Administration Act 1982 Mental Health Act 1990 Poisons and Therapeutic Goods Act 1966 Children and Young Persons (Care and Protection) Act 1998 State Emergency and Rescue Management Act 1989 Other Regulations NSW Treasurer s Directions Privacy Code of Practice for NSW Health Public Sector Code of Conduct NSW Ombudsman - Good conduct and administrative practice: guidelines for public authorities and officials NSW Department of Health Circular 99/34 State Records Act 1998 NSW Department of Health Policy Directive PD2005_127 Principles for the Creation, Management, Storage & Disposal of Health Care Records NSW Department of Health Accounts and Audit Determination 3.2 Records Standards The Records Management system is underpinned by the standards, policies and codes released by the State Records Authority. The Designing and Implementing Record Keeping Systems (DIRKS) methodology has been employed to ensure these standards, policies and codes are met. Counter Disaster strategies for records and recordkeeping systems Standard on Managing a Records Management Programs Standard and Full and Accurate Records Standard on Physical Storage of State Records Standard on Recordkeeping in the Electronic Business Environment NSW Recordkeeping Metadata Standard Policy on Electronic Recordkeeping Policy on Electronic Messages as Records Policy Building the archives: Policy on records appraisal and the identification of State archives. Code of Best Practice in Recordkeeping AS4390 Information and documentation Records Management ISO 15489 Page 5 of 17
4. Overview of Records Management 4.1 What is a Record? Records are: Information in any form, created, received or maintained in the transaction of business or conduct of affairs and kept as evidence of such activity Australian Standard for Records Management AS 4390 It is the evidential nature of records that make records valuable. Records provide evidence of jurisdiction, rights, assets, past decisions, legal obligations, actions undertaken, and provide a corporate memory which can be used to improve the outcome of daily operations. Over time records provide the Ambulance Service with the continuity to inform current staff about the decisions of previous staff. It is essential that this knowledge is passed on in a systematic and organised way so that it can be retrieved and used. 4.2 What is a File? A file is a collection of records that pertain to a particular function, activity, issue or topic. Files are registered in the Records Management system and are classified according to the Service s corporate thesaurus. Each unit maintains and stores its own files for as long as they are required as active records. 4.2.1 Official files and Working files All records should be placed on an official file. Official files are registered on an approved official register. The computerised register used by State Headquarters is TRIM which will be available to all Sector, Operations, Divisional (Finance/Admin) offices State-wide by December 2007. Areas that do not have access to TRIM should create files and record them on a local register such as an Excel spreadsheet or Word document. Many officers maintain working files, which can consist of copies of records, copies of circulars, working papers, background information, and drafts. Officers can maintain their own working files, as long as: no records are placed in working files (copies of records may be placed in working files, as long as the relevant originals are on an official file) records contain adequate evidence on how and why an outcome was reached (eg a decision made), and do not rely on drafts or working papers for this evidence (if they do, the drafts/working papers should be placed on the official file). However, staff should endeavour to limit the use of working files wherever possible. Page 6 of 17
4.3 What is Records Management? Records Management is the systematic control over all records the Ambulance Service needs to do its business. It is concerned with the unique documents which record the decisions made by staff as they carry out their daily tasks. These records must be placed in an official system and indexed so they can be retrieved whenever they are needed. It is important to capture current information quickly into the system as this ensures the most current information is always accessible quickly and easily and prevents backlogs from accumulating. This policy sets out the best professional practice of Records Management. These are based on three principles: Preserve your information Know your information Share your information 4.3.1 What sort of things should be recorded and preserved? Generally all documents created or received in the course of conducting Ambulance Service business are official records and should be placed on file. Using information technology often means communication can be informal and sometimes it can be difficult to decide whether the communication should be kept or not. Records must be kept if they: Are evidence of a contract, agreement, or negotiation (Note: Contract records have additional requirements, refer to Instructional Circular IC04/03.) Variations to agreements after they have been signed Record an approval under delegated authority Signify a change in policy Provide advice to the Minister or Director-General of Health Record investigations by the Ombudsman, ICAC, Parliament, Royal Commissions, courts or tribunals Record investigations carried out by the Service Create a precedent Provide legal advice Are information conveyed to outside agencies, organisations and unions Are evidence of community consultation regarding ambulance services Conversations, meetings and correspondence where responsibility is assigned or accepted for items, actions or deliverables Conversations, meetings and correspondence where a decision is made Directions by management and outcomes of management decisions Page 7 of 17
Strategy papers Are a record of complaints Are a record of threats received Proposals, implementation plans and approvals to proceed Record achievement of milestones Are part of a tendering process Submissions, reports, studies, recommendations, or reviews Are proof of payments Provide evidence of investment of funds from fundraising or disbursement of funds from fundraising Finalised financial documents Document workers compensation claims, rehabilitation of injured employees, or compensation claims from the general public Most records are created by an action, such as writing a submission or email. However some records need to be purposefully made as soon as possible after the event. For example Minutes of meetings are written, typed up and distributed Confirming emails of phone conversations, verbal agreements or informal meetings where a decision is made or responsibility assigned or accepted File notes of decisions, actions taken, and outcomes Personal notes, copies of circulated documents, and records of short-term facilitative value (such as emails arranging meeting times) do not need to be retained as records. 4.4 Vital Records and Business/Disaster Recovery Programs Vital records are those without which the organisation could not function. In identifying vital records, consideration should be given to those records which are needed to: 1. Operate the organisation during an emergency or disaster 2. Re-establish the organisation s functions after an emergency or disaster 3. Establish and protect the rights and interests of the organisation and its clients The Ambulance Service will continue to develop business/disaster management plans for vital records in accordance with identified needs Page 8 of 17
5. Recordkeeping Requirements Good recordkeeping does not presume inclusion on a centralised database but should be observed by all staff as part of their daily work practices. The standards and guidelines for general records management supported by this policy are applicable to all records in all formats, locations, and recordkeeping systems. 5.1 Creation of Adequate Records Records need to be created to ensure there is sufficient reliable proof of what both individuals and the organisation itself have done, decided to do, or the position they have taken on a matter. All employees are obliged to create records that adequately document the business they take part in. It is also essential to ensure that information and processing systems that support the Service s activities create appropriate records as part of conducting those activities. Systems can include automated payroll systems, the CAD system, and financial systems. 1. Section 4.3.1 of this Policy outlines minimum level of documentation required to be made and kept 2. Detailed instructions on creating adequate quality records can be found in the Users Procedure Manual 5.2 Capture and Registration Records need to be captured into the Records Management system to ensure the Ambulance Service s knowledge is preserved in a useable, reliable form and easily retrieved when needed. Records are made meaningful by their context, which recordkeeping systems document through documenting the activity that produced the records and relationships with other records on the same matter. Records should not be hoarded or purposefully excluded from the official system. 1. All Ambulance Service records must be registered in a records management system, with appropriate security restrictions to ensure confidentiality and privacy, and classified using the Service s functional thesaurus. 2. The originator, or recipient of an external record, is responsible for ensuring the record is registered in the system with appropriate security restrictions. 5.3 Classification Classification is the process of identifying the context and purpose of records and assigning related records to the same file. It uses a classification scheme (the thesaurus) as a tool to describe the Ambulance Service s work consistently over time. Records need to be classified in a consistent and systematic way to ensure they are able to be found, understood and managed. The thesaurus is a collection of authorised terms that describe the different types of activities the Service undertakes. These terms provide a common language across units that may use different words to talk about the same thing. Classifying records using the thesaurus greatly enhances the management and disposal of large volumes of records. Page 9 of 17
1. All files must be classified using the corporate functional thesaurus 2. Documents and other related items must be attached to the relevant official file as soon as possible after receipt or production 3. Where records are of a size or shape that they cannot be attached to an official file, the item must be registered and associated with the official file 4. Any directories used to store electronic documents should be titled and structured according to the thesaurus to provide consistent organisation of information 5.4 Maintenance and Storage Custody, maintenance and access to records is provided by staff and coordinated by the Records and Mail Services Unit. Staff are encouraged to use local storage areas to enhance access to their commonly used records. Appropriate security to protect confidential and private information must be observed at all times. 1. Lateral filing cabinets are the preferred storage option. They are more space efficient than drawer filing cabinets, and recommended for their protective features 2. Local storage areas are the responsibility of the unit or group that uses them and are subject to regular audits and culls by the Records and Mail Services Unit. This is to ensure standards are maintained and overcrowding is not problematic 3. All records should be stored securely at the end of the day before leaving the office. This includes closing cabinet doors and locking them 4. Confidential records should always be kept in locked cabinets in controlled environment (such as an authorised office) 5.5 Movement and Location Changes It is essential that the location index is kept current to stop records from becoming lost. Each staff member is responsible for moving on TRIM files and records which they pass onto others, or return or retrieve from storage. 1. The location of the physical record must be updated by the person who gives the record to another person 2. The location of the physical record must be updated by the person who takes a record from storage 3. Records remain the legal responsibility of the last identified user Page 10 of 17
5.6 Disposal of Records Records, regardless of format, are not to be destroyed by staff. Destruction of records is carried out as part of the Records Management programme in a systematic, managed and documented manner that satisfies requirements of the legislation with which the Ambulance Service must comply. The disposal authorities under which the Ambulance Service is authorised to dispose of records are: DA18 Disposal authority for the Ambulance Service of NSW GDA 12 General disposal authority for administrative records GDA 3 General disposal authority for personnel records GDA 4 General disposal authority for Records of Short Term Value That Have Been Imaged GDA 6 General disposal authority for year 2000 project records GDA 7 General disposal authority for financial and accounting records Disposal is the responsibility of the Records Coordinator 5.7 Electronic and Email Records 5.7.1 How should electronic records be kept? Electronic records have the same status as other records and electronic records generated or received by Service staff in the course of official duties are to be treated as official records. As such they must be created, maintained and protected just as with other records. All staff that have access to TRIM are required to save email records into TRIM. Staff that do not have access to TRIM should print and file email records on the appropriate subject file dealing with the content matter of the email. 5.7.1.1 Create and Capture The way electronic records are proven to be authentic, reliable and accurate for legal, audit and other purposes is more complicated than for other records, making the procedures used to provide and store the record critical to its long term value. Capture into a recordkeeping system at the earliest practical point ensures that these criteria for maintaining their evidential value are met though the use of database audit trails. Integrated records management systems enable electronic and paper to be coherently brought together, creating a complete record of an issue or activity and enabling lifecycle management of the information. Where a record s primary nature is electronic it should be preserved as an electronic record within the Records Management system. This can include but is not limited to Email Electronic faxes Websites / web pages Databases Streamed media Page 11 of 17
Multimedia and graphics productions Electronically recorded audio and video files Office documents (e.g. spreadsheets, presentations) All staff are responsible for correctly saving their electronic records on official files in the records management database. All staff are responsible for saving email records into TRIM. Staff that do not have access to TRIM are required to print and file email records on the hardcopy file dealing with the subject matter. Where electronic records are produced for the purpose of being printed, such as reports, letters requiring signature and legal documents, the printed and signed version is taken as the master record and attached to the hardcopy file. Where records are produced electronically only and do not exist in hardcopy the electronic original should be considered the master record. This may include: Large spreadsheets Photographs Documents communicated externally in electronic format Training and support for managing electronic records will be provided by Records staff on an individual and case by case basis. It is not the intention to implement a complete electronic records management environment at this stage. However, this is will be considered in future Information Management strategies in conjunction with Information Systems and Support Unit and, will be subject to the IT infrastructure capabilities at that time. 5.7.1.2 Maintain and Store Electronic records have special needs in order to be accessible and useable over time. Software packages, operating systems and complex databases are constantly being updated and sometimes discontinued, leading to loss of functionality and in the worst case, total loss of readability. It is important to identify the functionalist and format of electronic records early in their life in order to plan appropriate intervention before they become inaccessible. Ensuring the long term accessibility and authenticity of electronic records is the responsibility of the Records Coordinator in consultation with the Manager Technology Services. Section 14 of the State Records Act places an obligation on public agencies to maintain accessibility to equipment/technology dependent records. The Ambulance Service is required to implement strategies to ensure that electronic records can be read over time and that their on-going accessibility is ensured. These obligations are designed to ensure better management of New South Wales Government records, promote more accountable government through improved recordkeeping and provide better protection for the State s archives. (From State Records NSW Guidelines Future proof Ensuring the accessibility of equipment/technology dependent records.) Page 12 of 17
5.7.1.3 Disposal Official records cannot be destroyed without approval of the Records Coordinator. Official records, including significant drafts of major documents, should always be stored in the records management database. Drafts and documents created or kept for personal information are not records and can be deleted in accordance with normal administrative practice. Prior to destroying any records please contact the Records Coordinator for further information on procedural requirements in relation to the State Records Act 1998. 5.7.2 Email Email is part of the official communication system of the Ambulance Service. Email sent or received in the course of conducting business contains evidence about the business of the Service and therefore forms part of the Ambulance Service s official records. That is to say, electronic messages documenting substantive business transactions must be kept in a recordkeeping system. Many email messages are ephemeral and only need to be kept for a short time. All disposal of electronic messages must be done in accordance with the State Records Act, disposal authorities and this Policy. See section 5.6 for further information on authorised disposal. Email sent or received in the course of official duties and documenting substantive business are records The same minimum documentation requirements stated in section 4.3.1 of this Policy apply to email. All electronic records, including email, are required to be managed electronically using the records management system Ephemeral, personal and transient value emails not required as records of business can be deleted under Normal Administrative Practice 5.7.3 Making Use of Electronic Recordkeeping As an index of physical files and documents, the records management database provides an electronic register of the Service s records. It is possible to use this electronic register to store related electronic information within each database folder. For example, if a file is registered about transporting patients contaminated with a hazardous substance, it is then possible to add electronic records into the corresponding electronic folder within the database, in much the same way as Windows folders contain documents. The additional benefit is that if the staff member leaves the electronic records are not lost as they form part of a larger resource of corporate knowledge. They are also protected from network purges and accidental overwriting. Page 13 of 17
Electronic capture into the database can be achieved by: 1. Archiving completed records by drag and drop techniques 2. Utilising a specific software application to facilitate retrieving and updating records already saved in the database 3. Utilising a specific software application to bulk import electronic records from Windows 4. Cataloguing email directly through a link button 5. Programming interfaces between the records management database and another information system 6. Responsibilities 6.1 The Chief Executive Officer The CEO has overall responsibility for the Ambulance Service s records. The CEO ensures that: the Service complies with the State Records Act and regulations (section10). ensures compliance with other legislation relating to records 6.2 General Managers and Directors The General Manager and Directors of operational and support programs are responsible for ensuring that systems and staff in their programs comply with this Policy and related requirements. 6.3 Supervisors Supervisors of other employees must be familiar with the Service s Users Procedure Manual and ensure their staff operate according to the procedures. Supervisors are responsible for the security and care of official records under their control and must ensure confidential records are not compromised. They must: notify the Records Coordinator when staff leave their position ensure the orderly handover of records to new staff delegate security access to TRIM Page 14 of 17
6.4 Records Coordinator The Records Coordinator has overall responsibility for the management and coordination of the Records Management system including: system design, performance and review in compliance with the State Records Act development of recordkeeping procedures, including local procedures development of strategic and operational plans and budgets formulation and maintenance of the thesaurus and disposal authority management of the recordkeeping system database (TRIM) coordinate vital records and disaster recovery planning and operations management of disposal programs management of inactive and archival storage liaison with Department of Health and State Records Authority in relation to records and archives development and conduct of training in records management practice, the Ambulance Service s recordkeeping procedures, and use of the records database provide consultation and advice services to management and staff for recordkeeping approve local recordkeeping registers 6.5 Records Management Officers The records management officers are responsible for coordinating and maintaining records in the records management system. The records management officers create official files when requested by: registering the file on TRIM applying appropriate classification and security restrictions creating a physical file cover (where appropriate) locating the file as directed Page 15 of 17
They are also responsible for: performing regular file audits searching for and retrieving records registering external mail opened in the mail room filing hardcopy records sent loose to Records for filing assist staff with moving and maintaining files responding to resubmits assist with the identification and disposal of inactive records coordinating access to restricted records providing advice to staff on records management, use of the records management system and procedures, and TRIM maintaining the records management system database as up-to-date and removing duplicate index entries and prepare records for storage or archiving maintenance of inactive storage areas 6.6 All Staff All staff are accountable to their supervisors for compliance with this policy and with related policies, standards and guidance. All staff are responsible for creating accurate records of the activities and decisions, including appropriate data such as date, author and file references. Staff must ensure all their records are captured on the relevant official file by: requesting a new file as soon after a new matter arises as practical requesting new file parts as necessary sending hardcopy records to Records for filing (if they don t have the file) filing hardcopy records on files they currently hold capturing email records electronically into a file in the records management system or, print and file on the hard-copy TRIM file. capture electronic records by attaching them electronically to file in the records management system or, print and file on the hard-copy TRIM file. Page 16 of 17
Staff who receive mail unopened are responsible for ensuring that it is registered into TRIM if: it is a legal document it is a Ministerial it is from the Director-General of Health it requires action tracking (workflow). Staff are responsible for registering the following types of documents into TRIM: letters being sent to an external organisation all Briefing Notes all Email records Page 17 of 17