PROCEDURE REF. SABP/QUALITY/0035 NAME OF PROCEDURE REASON FOR PROCEDURE WHAT THE PROCEDURE WILL ACHIEVE? WHO NEEDS TO KNOW ABOUT IT? Integrated Paper and Electronic Health Records To ensure effective and consistent management of health records across the Trust. Single, unique, integrated health / social care record. All staff who engage with people who use Trust services and / or Trust health records. DATE APPROVED 25 November 2014 VERSION NUMBER 5.0 APPROVING COMMITTEE Executive Board DATE OF IMPLEMENTATION November 2014 DATE OF FORMAL REVIEW November 2017 AUTHOR/REVIEWER: RESPONSIBLE DIRECTORATE DISTRIBUTION Records Manager Quality Trustwide Page 1 of 19
INTEGRATED PAPER/ELECTRONIC HEALTH RECORDS PROCEDURE VERSION CONTROL SHEET (Instructions for completion available in Appendix A2) Version Date Author Status Comment 3 13 October 2009 Elaine Gould Timothy Lloyd 4 13.09.11 Clare Roughley Amendments made, detailed on next sheet. 5 07.10.14 Clare Roughley Review Amendments made detailed on next sheet. 5 16.10.14 Clare Roughley Amend Amendments made, detailed on next sheet 5 21.10.14 Clare Roughley Amend and add Amendments made, detailed on next sheet, add annexe 3 5 24.10.14 Clare Roughley Amend Amendments made, detailed on next sheet 5 03.11.14 Clare Roughley Final Formatting and contents page up date 5 13.11.14 Clare Roughley Amendments Amendments detailed on next sheet. 5 18.11.14 Clare Roughley Formatting and contents page 5 04.12.14 Clare Roughley Final Amendments detailed on next sheet Page 2 of 19
INTEGRATED PAPER/ELECTRONIC HEALTH RECORDS PROCEDURE Version 5 Summary of Changes since Version 4 Page /Paragraph/ Appendix Number (select the appropriate action) Procedure Front Cover Scope Dividers Page 7 Original / New / Amendment / Deleted Statement (select the appropriate action) Change Title: from Integrated Paper/Electronic Health Record New: Integrated Paper and Electronic Health Record That will follow users of Trust services wherever they are treated Deleted the word RIO revised to: The Standard Operating Procedure for the electronic record and word Scope changed to Introduction Add: For the purpose of this document health records applies to the integrated care record produced by Surrey & Borders Partnership Foundation NHS Trust for a person who uses our services. Change Scope to: Roles and Responsibilities: All Health and Social Care Professionals and any staff who either access, create or add to the records have a responsibility to ensure this procedure is followed. Delete Crisis Team Add: The following procedure is the Trust process and guidance to ensure all Staff are aware of their continuing responsibility for the confidentiality, Maintenance, transporting, tracking and retention of the existing 403,000 Trust paper health records (as at 1 st December 2014) and the process for creating any new paper records where it has it has been agreed that there was a reason or a Service which would continue to do so. Page 8 Page 6 of 12 First paragraph add: The Trust has agreed that an Orange Document Wallet can be created and used in conjunction with the electronic health record, but strictly in accordance with Annexe 1. Deleted: Tracking mechanisms should therefore record the following (minimum) information: 5.2 Add: The electronic Casenote Tracking System is now the method used for tracking the movement of all health records and should contain the following minimum information Deleted: Identification of location/base. A description of the item (e.g., the file title). The person, unit or department, and location to which it is being sent. The date of transfer. Name of person sending file. NHS Number Page 3 of 19
Added: Name, Date of Birth and NHS No of the person who uses our services. Details of the Team who registered the file including location and the date if was created Description of the file e.g. initial, integrated, old style volume or Orange File. The person and location to where it is being sent. Recorded as received on casenote tracking when it arrives at that location 5.3 Deleted: moved to 5.2 5.4 Deleted: added to 5.2: The electronic casenote tracking system is now the method used for tracking the movement of records internally within the Trust. 8.1 Revised: Any professional within the Trust who is not actively involved In the provision of care, but wishes to access records for information, must make a request to the holder of the records which will be indicated on the casenote tracking system. 8.2 Deleted: The author of the record must consult with their manager before deciding if it is appropriate for the request to be granted. (Seek advice from the appropriate Records Manager). Added: The health record will then be sent to and received at the new location using the casenote tracking system. 8.3 Deleted: If the request is granted this must be recorded and the Individual making the request reminded about their responsibility for confidentiality. Added: Health records must not be photocopied without prior approval via the Records Managers and the subject access request process. 8.5 moved to 8.4 Deleted: Under no circumstances must any information in the records be divulged to the person who uses our services or carer, without prior permission from the author. Added: No information in the records should be divulged to the person Who uses our services or carer, without prior permission from the author or unless a subject access request has been processed by the Records Managers. 8.6 Deleted: Where there might be excessive delay in consulting the author, the Appropriate Records Managers should be consulted for advice. 8.7 Moved to 8.5 Page 4 of 19
10.4 Revised: Original records should not be sent out of the Trust but if copies Are being transported by post then they must be sent by Recorded delivery and it is the Service Leader s responsibility to ensure that the transportation mode is appropriate and safe and follows Trust guidance. 11.2 Deleted: on the pro-forma for missing records as soon as the search commences. The pro-forma is used to record details of the search locations and staff involved. This will avoid duplication in effort if the search needs to be extended later Add: on the casenote tracking system 11.3 Deleted: The pro-forma should be updated and used as a check list to ensure all possibilities have been considered. The checklist is not exhaustive and the knowledge of staff working in the service will very often uncover all of the possible avenues for follow up. 11.3 Revised to include reporting on Datix: Add: If after 5 working days the case notes have not been located then an incident report should be completed on Datix which will then be forwarded to the manager/service co-ordinator. It may then be necessary to compile temporary notes to manage the care of the person who uses our services. If this is the case then the casenote tracking system should be updated with this information. 11.3 Amend: the Records Managers should be advised and the casenote tracking system updated with this information. Advised to delete all footers except Page numbers 12 Revised: It is therefore expected that all integrated multi-disciplinary records in use both paper and electronic will confirm to the following guidelines: 13 Add: the progress notes must be validated on the electronic patient system. 13 Add: The Electronic patient recording system which is now the primary care record for the Trust is subject to the same principals as paper health records in terms of standard of records keeping, confidentiality, accessing, and minimum retention periods. The Standard Operating Procedure can be located on the Trust intranet. 14 Moved to 15 13 Addition: All letters, documents and reports temporarily retained on staff O Drives, should be deleted once they have been scanned onto the electronic patient record. Page 5 of 19
15 Deleted: Faxes which are likely to fade with time (i.e. those produced on thermal paper) must be photocopied before being put in the file. Changed to: Electronic records are password protected and passwords are role specific. Access to the electronic system is monitored and audited. 15 Now 16 18 Added: Orange document wallet file flow chart Page 6 of 19
Contents Page no. Introduction 8 Roles and Responsibilities 8 Sensitive Information 9 Carer s Needs Assessment and Information 10 Maintenance of records 10 Record Tracing systems 10 Storing paper records 11 Retrieving records 11 Accessing records 11 Monitoring records 11 Trust audit process 12 Transporting health records 12 Lost records 12 Standards of record keeping 13 Retention and disposal schedules 14 Electronic health records 14 Training 14 Monitoring and review arrangements 15 Annexe 1 Contact details for Records Management 16 Annexe 2 Orange document wallet process 17/18 Annexe 3 Orange document wallet flow chart 19 Page 7 of 19
INTEGRATED PAPER/ELECTRONIC HEALTH RECORDS PROCEDURE Introduction For the purpose of this document, health records applies to the integrated care record produced by Surrey & Borders Partnership Foundation NHS Trust for a person who uses our services. In December 2009, the Trust implemented an Electronic Health Record System which superseded the paper file and is now used to create health records for all the people who use our services. The Trust has agreed that an Orange Document Wallet can be created and used in conjunction with the electronic health record, but strictly in accordance with Annexe 2 attached. The complete process and guidance for creating electronic health records can be found in the Standard Operating Procedure which is located on the Trust intranet. The following procedure is the Trust process and guidance to ensure all Staff are aware of their continuing responsibility for the confidentiality, maintenance, transporting, tracking and retention of the existing 403,000 Trust paper health records (as at 1 st December 2014 ) and the process for creating any new paper records where it has it has been agreed that there was a reason or a service which would continue to do so. Roles and Responsibilities: All Health and Social Care Professionals and any staff who either access, create or add to the records have a responsibility to ensure this procedure is followed. 1. Integrated Health and Social Services Records of Care, Treatment and Support The record contains entries recording facts and observations written at the time of, or soon after, the event described (within 24 hours). Local arrangements indicating where information must be recorded if case notes will not be in the base/unit for over 24 hours must be established. It is essential that any case notes follow the person who uses our services as soon as possible after discharge from one base/unit to another. All case discussions should be recorded in the records relating to people who use our services Every effort must be made to validate any anecdotal or unclear information 1.2 Integrated Paper Record 1.2.1 The Integrated Record case note will be divided into the following sections: 1. Referral/Assessments & Care Plans 2. CPA & Risk Assessment Page 8 of 19
3. Medication 4. Investigations 5. Safeguarding 6. Correspondence 7. Continuous Clinical record 8. Social Inclusion 9. Housing & Finance 10. Miscellaneous 11. Carer s Needs Assessment 12. Sensitive Information Additional dividers that can also be used include: 1. Mental Health Act 2. Psychological Therapies 3. Continuous Clinical record Psychology 4. Multi-Disciplinary Groups 5. Inpatient Nursing Notes 6. Advance Directives 7. Blank 8. Learning Disability Disciplines (CTPLD Teams) 1.2.2 All records will be filed in chronological order. 2. Sensitive Information 2.1 Sensitive information is any information deemed by the professional involved, in consultation with their service/professional lead, to be of a nature that might be emotionally upsetting, or affect treatment outcomes and therefore requires its availability and accessibility to be restricted from other professionals and/or the person who uses our services. 2.2 Sensitive information might apply to information recorded by professionals from services such as psychotherapy or eating disorders or information on child protection issues, where appropriate. 2.3 A summary of the information must be placed in the main record. 2.4 All sensitive information will be sealed in an envelope with clear instructions on the envelope stating who can have access to the information and filed in the main case file. 2.5 It is imperative that all staff are made aware that sensitive information is not for general use and must be treated accordingly. Page 9 of 19
2.6 Any member of staff found to be misusing sensitive information would be subjected to disciplinary action in accordance with regulations on confidentiality. 2.8.1 Sensitive information must not be photocopied under any circumstances. 2.8 Sensitive information will only be accessed after permission from the author and clearance from a health Records Manager and/or professional lead. If the author of the information has left the Trust, then access will be decided by the service/team manager. 3. Carers Needs Assessment and Information 3.1 A separate section will be created for the current Carers needs assessment, care plan and information. 3.2 The guidelines and principles of confidentiality and access to records will apply. 4. Maintenance of Records 4.1 Each Service Lead / Social services manager will be responsible for ensuring that all professionals adhere to the procedure. 4.2 Each service/team will identify one person (Records Administrator) who will be responsible for: Practical administration of agreed procedures Maintenance of integrated health & social services records Ensuring new volumes are available and are created when needed 4.3 However, professionals and other care staff are responsible for ensuring that their part of the file is organised and filed chronologically and the file is kept secure in a locked filing unit when not in use. 5. Record Tracing Systems 5.1 Records are only of value for the information they contain and then only of value if they can be found when needed and used effectively. 5.2 The electronic Casenote Tracking System is now the method used for tracking the movement of all health records and should contain the following minimum information: Name, Date of Birth and NHS No of the person who uses our services Details of the Team who registered the file including location and the date it was created Description of the file e.g. initial, integrated, old style volume or Orange File The person and location to where the file is being sent Received on Casenote tracking when it arrives at that location Page 10 of 19
5.3 Each team/service will adhere to the tracking method of records as above and ensure that all record movements are recorded on the appropriate system. 6. Storing Paper Records 6.1 Records in constant or regular use or likely to be needed quickly must be kept within the teams responsible for the related work. 6.2 Records must always be kept locked away when not in use, where possible, in lockable filing units. Where this is not possible, the room containing records must be locked if left unattended. 7. Retrieving Records 7.1 Trust staff are responsible for checking the electronic Casenote Tracking system and any appropriate previous local manual systems to locate records. Staff should follow local procedures for retrieving records, but once located use the electronic tracking system to record their location. If staff are uncertain of any local procedures prior to Casenote tracking, they should contact the Records Department for details (See Annexe 1). 7.2 Managers are responsible for ensuring that all staff adhere to the Casenote tracking procedures. 8. Accessing Records 8.1 Any professional within the Trust who is not actively involved in the provision of care but wishes to access records for information, must make a request to the holder of the records which will be indicated on the Casenote tracking system. 8.2 The health record will then be sent to and received at the new location using the Casenote tracking system. 8.3 Health records must not be photocopied without prior approval via the Records Managers and the subject access request process. 8.4 No information in the records should be divulged to the person who uses our services or carer, without prior permission from the author or unless a subject access request has been processed by the Records Managers. 8.5 If records are required following a complaint or serious untoward incident, a fast track system shall apply. 9. Monitoring of Records 9.1 The Trust and Social Services will set up and implement an annual programme of auditing and monitoring records. The Trust Information Governance Lead and Record Manager will be responsible for developing a comprehensive audit programme. Page 11 of 19
9.2 The purpose is to audit health and social services records to ensure that they meet Caldicott, Department of Health, Social Services, Statutory and NHSLA requirements. 9.3 The Mental Health Act manager will continue to audit and monitor the statutory records. 9.4 Trust audit process will involve: Copy of audit tool made available to all teams and services Findings of audits fed back to teams and directors An action plan Audit reports will be monitored via the Information Governance Steering Group and Quality Assurance Group. 10. Transporting Case Files 10.1 The nominated Records Administrator for each team/service will be responsible for ensuring that any transportation of records is safe and appropriate preferably by Trust transport. 10.2 Before any records leave their located site, the Records Administrator must be informed and they will check how the records are going to be transported. All movements of case notes must be recorded on the electronic Casenote tracking system. 10.3 It is the responsibility of the individual professional transporting the records to ensure that the records reach their destination in good condition and on time. 10.4 Original records should not be sent out of the Trust, but if copy records are required externally then the Trust Access to Health Records Procedure should be followed and processed by the Records Managers. Copy records should only be sent externally by recorded delivery. 11. Lost Records 11.1 A lost/missing record is defined as a record that is not filed in the location where it is expected to be. This might be because the entry on the tracking system used has not been updated and highlights the need for services to ensure that clear responsibilities are assigned for updating the appropriate tracking system. 11.2 On the discovery that a record is missing or lost, an initial search must be carried out. Local procedure should dictate who conducts the initial search but this must be recorded on the Casenote tracking system. 11.3 Conducting a formal search/investigation: If after 5 working days the case notes have not been located, then an incident report should be completed on Datix. This will then be forwarded to the manager/service coordinator. It may then be necessary to compile temporary notes to manage the care of Page 12 of 19
the person who uses our services. If this is the case then the Records Managers should be advised and the casenote tracking system updated with this information. It is also important in the case of multiple records to indicate which volume of notes has gone missing. The formal investigation and search will involve a systematic review of all possible staff and locations that the notes might have been in contact with. 11.4 Creating a duplicate record: Should the missing record remain missing after 5 days, the case holder (e.g. Care Coordinator, Named Nurse, Consultant) should create a replacement or duplicate record. This record must be identified as a duplicate on the front cover and must be created in accordance with local policy (e.g. using the local unit/team format). The appropriate electronic and manual case note tracking systems MUST be updated and the Central Records department informed that a duplicate record is being created. 11.5 If the original record is found, Remove the new information from the duplicate file and re-file appropriately and chronologically within the original file. The duplicate file must then be destroyed and recorded appropriately on the case note tracking system. Again, the decision must be communicated to the Records Department and the case note tracking systems must be updated. 12. Standards for Record Keeping The principles underpinning record keeping include, where possible: The involvement of people who use our services and their carers in the formulation and evaluation of care plans Providing clear evidence of the care planned, the decisions made, the care delivered outcome and the information shared Identifying problems that have arisen and the action taken to rectify them It is therefore expected that all integrated multi-disciplinary records in use both paper and electronic and will conform to the following guidelines: 1. All records will be factual, consistent, accurate and evidence-based. Where records are professional opinions, this must be clearly stated. 2. Records will be written as soon as possible after a contact has occurred, providing current information on the care and condition of the person who uses our services (within 24 hours). 3. Local arrangements must be put in place to indicate where such information will be recorded if the notes will not be in the base/unit for over 24 hours. 4. Records will be written clearly and legibly in such a manner that the text cannot be erased. Page 13 of 19
5. Records will be written in permanent black ink or typed, printed, signed and filed immediately. 6. Records will be readable on any photocopies. 7. Records will be written in such a manner that any alterations or additions are dated, timed and signed, in such a way that the original entry can still be read clearly. 8. Alterations will only be made by scoring through with a single line. 9. Correction Fluid (e.g. Tippex) must not be used in any circumstances. 10. Records should avoid abbreviations or jargon. 11. The use of and the writing of records for irrelevant speculation, or offensive subjective statements, is both an abuse and unprofessional. 12. Records will be accurately dated, timed, and signed, with the name and title printed alongside. 13. Entries by unqualified staff will be countersigned by qualified staff (see individual professional guidelines) in the paper records and the progress notes must be validated on the electronic system. 14. All records will be securely stored and their confidential nature respected. 15. Electronic records are password protected and passwords are role specific 16. Access to the electronic system is monitored and audited. 13. Retention and Disposal Schedules 13.1 It is a fundamental requirement that all of the Trust s records are retained for a minimum period of time for legal, operational, research and safety reasons. The length of time for retaining records will depend on the type of record and its importance to the Trust s business functions. 13.2 The Trust has adopted the retention periods set out in the Records Management: NHS Code of Practice (detailed in the Trust s Retention Schedules for Health and Non- Health Records). This can be accessed on the Trust Extranet or the Department of Health website. 13.3 Health records will be appraised by the Records Managers once they reach the end of their retention period to ascertain whether they should be confidentially destroyed or retained or permanently archived for historical purposes. 14. Electronic Health Records The EPR system, which is now the Trust s primary care record, is subject to the same principles as paper health records in terms of standard of records keeping, confidentiality, accessing, and minimum retention periods. All letters, documents and reports temporarily retained on staff O Drives should be deleted once they have been scanned onto the electronic patient record. The Standard Operating Procedure can be located on the Trust intranet. 15. Training Page 14 of 19
Trust Staff who have a responsibility for record keeping and record management will review with their line manager, through supervision and appraisal, whether they have any specific training requirements and provision in line with the training needs analysis in the Learning and Development Policy. 16. Monitoring and review arrangements The effectiveness of the arrangements described within this document will be monitored by the Information Governance Steering Group in accordance with the arrangements set out in 9.0 above. Any shortfalls identified will be dealt with through provision of training and inclusion in staff Personal Development Programmes. Page 15 of 19
Annexe 1 Records Management Central Records Library Trust HQ., 18 Mole Business Park, Randalls Road Leatherhead KT22 7AD Team 01372 216265 Records Manager 01372 216260/6261 e.mail address records.team@sabp,nhs.uk Page 16 of 19
Annexe 2 Orange document wallets process The orange wallet is supplementary to the electronic record. This file should only be created for the agreed documents listed below. Do not create a new Orange file if one already exists on casenote tracking, ask the holder to casenote track the file to your team. (see flow chart attached) If you do not have a shortcut or bookmark for CaseNotes, there is a link under Systems and Applications on TrustWeb. If your team is not yet registered to use CaseNotes, download the application from the Trust Web and send to the Records Team at Trust HQ. Orange document wallets can be ordered from SBS using the Banner reference 1230625. All documents including sensitive information should now be scanned to the electronic system and the wallets only used to file documents previously agreed cannot be scanned to the electronic record i.e. Psychometric raw data which cannot be uploaded due to copyright restrictions Bulky reports which are too large to be scanned ( i.e. 30 pages) Medication Charts these can be uploaded to the electronic system on completion of the treatment episode, but the originals must be also be retained as they are difficult to scan effectively. Reference to any of these documents held in the wallet must be recorded on the electronic system. Tracking an Orange File Clients Already Registered on CaseNotes 1. Search for the client using the Patient Search Screen 2. Click Select next to the relevant result. 3. Click Add New Case Note 4. Click the circular radio button next to Orange File 5. Check that the Location, Created By and Date Created have been populated with the correct information. 6. Click Save. Clients Not Already Registered on CaseNotes 1. Click the New Patient button at the bottom of the Patient Search screen. 2. Enter the demographic information and click Check (this runs a final search through CaseNotes to minimise the risk of a duplicate being created on the system). 3. If a match is found and you are happy that the match is the same client, click Select and follow the process for clients already registered on CaseNotes. If no match is found, click Save. 4. Click the circular radio button next to Orange File 5. Check that the Location, Created By and Date Created have been populated with the correct information. Page 17 of 19
6. Click Save. Once the person who uses service has been discharged the orange document wallet should be sent, using Casenote tracking to: the Central Records Library, Trust HQ., for archiving. Page 18 of 19
Annexe 3 Inpatient Wards Original documents which need to be kept in a paper file as per the Orange Document Wallet Process e.g. Original Medicine Charts Bulky Reports Psychometric raw data Flow Chart Check Casenote tracking to find out if an orange document wallet file already exists NO Create new file and register on casenote tracking, with Full Name, date of birth, NHS No., and the date and name of the creating team. YES Request file from current holder and when received enter date on casenote tracking RETURN FILE TO THE CENTRAL RECORDS LIBRARY Trust HQ., 18 Mole Business Park Leatherhead Track change of location on the casenote tracking system. Patient discharged from Ward Check all original med charts and only relevant paperwork has been filed in the Orange Document Wallet. Where necessary make reference to these documents in the electronic record. All other original documents once scanned onto the Electronic patient system should be destroyed. Page 19 of 19