1. Health Records Management Foundation Information Governance (IG) Policy Team NHS Connecting for Health

2. Key Learning Points  What is a health record  Characteristics of full & accurate health records  Why do we keep health records  Performance measure for health records  Responsibilities for health records  Record Lifecycle Management

3. What is a health record? A health record includes any information created by, or on behalf of, a health professional in connection with the care of a patient

4. What format can a health record take? A health record can cover a wide range of material:  Handwritten medical notes  Computerised records  Correspondence between health professionals  Laboratory reports  X-ray films and other imaging records  Photographs  Videos and other recordings  Audio recordings  Printouts from monitoring equipment

5. Characteristics of full & accurate health records  Authentic  Reliable  Complete & unaltered  Processes & systems have integrity  Useable  Transferable  Structured

6. Why do we keep health records?  Communication between healthcare professionals  Continuity & evaluation of patient care  Defence of claims & investigation of complaints  GMC Requirement (“Good Medical Practice”)  Risk management  Clinical Governance  Resource utilisation  Research and education  Historical purposes

7. The health record should be… Available in the right place at the right time to support effective patient/doctor contact and to provide continuity of care Availability of the complete record when needed is a key determinant of the performance of Health Record Services

8. Responsibilities for Records ‘All individuals who work for an NHS organisation are responsible for any records which they create or use in the performance of their duties….. any record that an individual creates is a public record.’ Records Management: NHS Code of Practice There are therefore INDIVIDUAL, STATUTORY & MANAGERIAL responsibilities for all NHS records, including health records

9. Record Lifecycle Management CreateUseRetentionDisposalAppraisal Close Record Be awareControlMonitor