Health Records Management Practitioner Information Governance Policy Team NHS Connecting for Health Welcome to the Health Records Management Practitioner training module produced by the Information Governance (otherwise known as IG) Policy Team of NHS Connecting for Health. This module is for Health Records Managers and their support staff directly involved in managing health records.

Key Learning Points Responsibilities for health records Record Lifecycle Management Auditing current health records practices & procedures Undertaking an records inventory survey of existing health records systems Drafting/maintaining the organisation’s health records management policy Drafting/maintaining the organisation’s health records management strategy & associated action plan Raising awareness of the importance of health records management throughout your organisation The key learning points of this module cover a number of topics. Responsibilities for health records Record Lifecycle Management Auditing current health records practices & procedures Undertaking an records inventory survey of existing health records systems Drafting/maintaining the organisation’s health records management policy Drafting/maintaining the organisation’s health records management strategy & associated action plan Raising awareness of the importance of health records management throughout your organisation The aim is to provide practical information based on good practice, which will enable you and your team to improve health records management in your organisation and improve compliance with the Information Governance Toolkit requirements.

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 All individuals who work for an NHS organisation are responsible for any records which they create or use in the performance of their duties. Furthermore, any record that an individual creates is a public record. There are therefore INDIVIDUAL, STATUTORY & MANAGERIAL responsibilities for all NHS records, including health records. 3

Record Lifecycle Management Create Use Retention Appraisal Disposal Close Record Any NHS record, including health records, created by an individual, up to its disposal, is a public record and subject to Information requests under the Freedom of Information and Data Protection Acts. It is imperative therefore, that records are closely monitored and managed throughout their Life Cycle. The life cycle of a record comprises of their: Creation – the need to Create and record accurate and complete information Use - Handle in accordance with the Data Protection Act Retention – After closure, keep and maintain records in line with NHS recommended retention periods Appraisal - Determine whether records are worthy of permanent, archival preservation (e.g. in Hospital and University libraries, The National Archives etc) Disposal - Dispose of securely in line with national guidelines. Above all there is a need to: Be Aware Monitor; and Control records throughout their lifecycle Be aware Monitor Control 4

NHS records may be subject to information requests Any NHS record may be subject to information requests under the Freedom of Information Act 2000 and the Data Protection Act 1998. It is important that records are controlled and managed in order to be able to consider any request for information within the prescribed time limits.

Health Records Policies & Procedures Policy and Procedure manual Key management tool Basis for specific training In this context, a procedure is a structured, action-oriented list of sequential steps involved in carrying out a specific job. It is a series of related steps designed to accomplish a specific task. The health record manager is responsible for planning and documenting the health records department's policies & procedures thus providing standardisation of work tasks throughout the health record department. All health records departments should have a policy and procedure manual to ensure that all staff members are undertaking their duties in a consistent way. The policy and procedure manual is a key management tool and forms the basis of all health record system specific training. Where there is no such documentation it should be a priority for one to be produced.

Auditing Health Records Policies & Procedures – The Audit Cycle Where procedure documentation does exist it should be regularly reviewed and updated to reflect any changes in the organisation, which require changes to the delivery of health records services. E.g. new IT systems, new buildings or services, changes in the delivery of clinical services. Auditing health records policies and procedures must be done carefully & systematically. Although audit is often described as a cycle it should not be seen as a “one off” exercise but as an on-going quest to improve and maintain standards. The audit will compare current operational practice against defined procedures. Use the audit cycle to help … Define criteria & standards – which means devising and documenting procedures which should be followed Data collection – meaning to observe and record how the procedures are working in practice. Assess performance against criteria & standards – by comparing the operational practice against documented procedures Identify changes – identify deviations from the documented procedure and investigate why those changes have happened Where there are deviations from/changes to prescribed practice it should be established whether they are due to systems change or changes within the organisation or whether staff are working inappropriately, Where changes are appropriate the procedure documentation should be amended accordingly. The health records manager should collate the updated documentation from each department or section and update the master copy of the procedure manual appending the date of the review and update and indicating the date when the documentation should next be reviewed.

Undertaking a Records Inventory Survey Guidance has been produced to help those organisations that have not yet started to establish a records inventory or are still in the in the early stages of completing one The guidance & a records inventory survey form are available in the records management roadmap www.connectingforhealth.nhs.uk/infogov/records and they are summarised in the following slides. The records inventory survey form has been designed to help NHS organisations compile their records inventory, or complete or update existing inventories. It is recognised that compiling a complete records inventory for an organisation, even a small organisation, is not an easy task. For most organisations, this will be a gradual process and one that, to succeed, will depend upon good organisation at the onset and the ongoing commitment and support of all staff. The guidance and records inventory survey form, which are available in the Records Management Roadmap, will help NHS organisations complete a records inventory survey effectively and efficiently.

Practical Steps A health records inventory is one component of the complete records inventory It can be completed in 3 steps Insert 3 step diagram   Step 3 8 Databases storing research information, etc Health Records 7 Electronic records replicating PAS e.g. waiting and clinic lists 6 Standalone clinical systems Step 2 5 Clinical systems (PAS fed) 4 Patient Administration Systems (PAS) Step 1 3 Scanned, microfilm records 2 Admission, day, ward books, diaries, index cards 1 Paper health records A practical way of compiling a health records inventory, is to do this in easy steps or stages, e.g. by targeting specific types of records or directorates/ department over a number of steps until all records have been covered. The health records inventory will form one component of the organisation’s complete records inventory. It is suggested in the guidance that, in an organisation which has not yet undertaken an inventory, the health records component would be a good first step. The health records inventory could be, for example, completed in three steps; with the first step covering Paper health records Admission, day, ward books, diaries, index cards Scanned, microfilm records

Distributing & Completing the inventory Distributing & Completing the Inventory Forms Aggregating the Inventory Form The inventory forms should be distributed and completed A batch of Records Inventory Survey Forms should be sent to each directorate or unit manager responsible for managing information sets/record collections. The forms can be sent out and returned electronically or by traditional hard copy; whichever works best for the organisation. All forms should be clearly marked with the closing date for return and the contact details of the Records Management Lead or other officer co-ordinating the return of the forms. A record should be kept of forms issued and returned so that outstanding forms can be chased up with the department leads. Managers should be asked to record details of ALL records/information sets they are responsible for even if they think they may be duplicating information provided by another department or manager. The completed forms should then be aggregated The Records Management Lead or designated officer will be responsible for aggregating the inventory of information sets/record collections into one corporate inventory. It is recommended that an electronic database is used to store the inventory and to facilitate comparative analysis of the data.

Benefits of a Health Records Inventory#1 Improves compliance with: Records Management: NHS Code of Practice IG Toolkit requirements NHS Litigation Authority’s risk management standards Standards for Better Health Professional standards The Health Records Inventory will be one component of the corporate inventory, which will help the organisation develop a Corporate Records Management Strategy. It will also allow the organisation to assess and ensure compliance with the NHS Code of Practice for Records Management, the Information Governance Toolkit Requirements, NHS Litigation Authority’s Risk Management Standards, the NHS Standards for Better Health and any other specific standards required by professional bodies.

Benefits of a Health Records Inventory#2 Informs the Board’s Assurance Framework Identifies managers and ‘owners’ Identifies sharing arrangements Identifies the format in which records are stored Allows mapping to retention schedules Ensures appropriate training Identifies storage conditions Identifies security arrangements It will also inform the organisation’s Board Assurance Framework, risk management and business continuity processes by: Identifying managers and ‘owners’ of records; Identifying information sharing arrangements both within the organisation and also externally; Identifying which records are stored electronically, which are stored on paper and those records which are ‘hybrid’ (i.e. stored partly electronically and partly on paper); Allowing records held to be mapped to current Retention Schedules to ensure compliance, and where appropriate, for superfluous, out of date or replicated records to be destroyed. Ensuring that managers and staff engaged in records management activities receive appropriate training; Identifying inappropriate, or pressure on, record storage conditions; and Highlighting deficiencies in security arrangements for records, including those electronic records which are not being routinely backed up.

Keeping the Inventory Up to Date The inventory needs to be accurate & kept up to date Health records manager must keep the health records inventory up to date Records management lead has responsibility for keeping the corporate inventory up to date To be effective in all of these areas, it is important that the completed inventory is as accurate as possible and is also kept up to date. Managers throughout the organisation, including the Health Records Manager, should be aware that when new collections of records or information sets are created or where management arrangements or physical locations change these changes should be notified to the Records Management Lead as soon as possible.

Health Records Management Policy A health records management policy applies to all types of health record regardless of the media on which they are held Its sets out a framework within which to develop specific policies and practices to ensure that health records are managed and controlled Model documentation is available in the records management roadmap A health records management policy sets out a framework within which the staff responsible for managing the organisation’s health records can develop specific policies and practices to ensure that these records are managed and controlled effectively, and at best value, commensurate with legal, operational and information needs. Once drafted the Health Records Management policy should be regularly reviewed and updated to ensure that it accurately reflects the current situation and the needs of the organisation. Model documentation is available in the Records Management Roadmap 14

Aims of a Health Record Management Policy To ensure that health records: are available when needed can be accessed can be interpreted can be trusted can be maintained through time are secure are retained and disposed of appropriately staff are appropriately trained The aims of a Health Record Management Policy are to ensure that: Health records are available when needed - from which the Trust is able to form a reconstruction of activities or events that have taken place; Health 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; Health 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; Health 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; Health 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; Health 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; Health 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; and Staff are appropriately trained - so that all staff are made aware of their responsibilities for record-keeping and health record management. 15

Drafting and maintaining a Health Records Management Strategy The health records management strategy applies to all health records of all types regardless of the media on which they are held; It should be an integral part of the organisation’s wider records management strategy and be compliant with the organisation’s records management policy. If the strategy and policy have not yet been written, model documentation is available in the records management roadmap The purpose of a Health Records Management Strategy is to identify the resources (human, financial & organisational) required to ensure that all NHS health records of all types are properly controlled, readily accessible and available for use when required and then eventually archived or disposed of in an appropriate way, regardless of the media on which they are held. It should be an integral part of the organisation’s wider records management strategy and be compliant with the organisation’s records management policy and once drafted it should be regularly reviewed and updated to ensure that it remains up to date and that it accurately reflects the current situation and the needs of the organisation in respect of health records management.

Aims of the Records Management Strategy Responsibility and accountability Record quality Management Security Access Audit Training The health records management strategy should follow closely the aims of the organisation’s records management strategy:- Responsibility and Accountability To provide a clear system of accountability and responsibility for record keeping and use Record Quality To create and keep records which are adequate, consistent, and necessary for statutory, legal and business requirements Management To achieve systematic, orderly and consistent creation, retention, appraisal and disposal procedures for records throughout their life cycle Security To provide systems which maintain appropriate confidentiality, security and integrity for records in their storage and use Access To provide clear and efficient access for employees and others who have a legitimate right of access to Trust records, and ensure compliance with Access to Health Records, Data Protection and Freedom of Information legislation Audit To audit and measure the implementation of the records management strategy against agreed standards Training To provide training and guidance on legal and ethical responsibilities and operational good practice for all staff involved in records management

Why do we need a Health Records Management Strategy? To provide a robust baseline from which to move forward; To identify how the management of health records is currently structured; To identify what health records the organisation generates and how they are archived and stored; To enable the organisation to meet existing and future demands for health records management; To ensure that the organisation meets it’s legal and statutory obligations in respect of health records; To help NHS organisations to improve the standard of health records management and to raise the profile of the service within the organisation. NHS Organisations need a Health Records Management Strategy to provide the organisation with a robust baseline from which to move forward. It will identify the current management structure for the health records service, the numbers and types of health records the organisation generates and stores to help to develop a plan to help the organisation meet existing and future demands of the service. It will also be a key enabler to help the organisation meet its legal and statutory obligations, improve the standard of health records management and to raise the profile of the service organisation-wide.

Tools to inform the strategy Records inventory survey Audit of HRM policies & procedures Assessment of environmental conditions Access controls for storage areas Assessment of tracing/tracking systems Mapping of records to retention schedule Review retention & destruction procedures Training provision Records Inventory Survey Audit of HRM Policies & Procedures to ensure that best practice principles are embodied within the policies and procedures and that the organisation complies with Records Management; NHS Code of Practice & Information Governance Toolkit. Review of records storage arrangements to check that environmental conditions are appropriate and to ensure that they facilitate efficient retrieval and effective management of records. Review of access controls for storage areas Assessment of the effectiveness & efficiency of the prescribed tracing/tracking systems Mapping of the records stored to the current Retention Schedule contained in the Records Management: NHS Code of Practice according to type of record, to check compliance with the Code of Practice and Principle 5 of the DPA i.e. Information is not kept for longer than is necessary Review of retention and destruction policies & procedures for health records Review of training provision to ensure that all managers and staff are aware of their responsibilities for keeping complete and accurate records and that their record keeping skills are kept up to date.

The Planning Cycle Use the Planning Cycle to help to produce a Health Records Management Strategy & associated action plan. The next few slides take you through the cycle, step by step.

Where are we now?#1 (Position Statement) Results of baseline audit - list the types and numbers of records and locations where they are stored and who is responsible for managing them; Describe environmental conditions; Document security & access arrangements to storage areas; In order to compile an accurate position statement the following information needs to be gathered or update:- information about the numbers and types of records stored locations where they are stored environmental conditions in the storage areas security and access arrangements for the storage areas Responsibility for managing the records in each of the various storage areas.

Where are we now?#2 (Position Statement) Document retention periods for all types of records in line with the current retention schedule and indicate the organisation’s compliance status; List existing policies & procedures including retention, weeding, archiving & destruction. In order to complete the position statement, retention periods for all types of records should be determined, using the retention schedules in Records Management: NHS Code of Practice. Existing health records management policies and procedures should also be documented.

Developing the Action Plan (Identifying Goals & Objectives) Is there a designated manager responsible for each collection of records? Are you storing more records than necessary? Is there sufficient storage space for them? Are environmental conditions appropriate & safe? Do you need additional storage? Do you need to look at archiving solutions? Are disposal & destruction arrangements appropriate? Describe the current position which will help identify those issues which need to be addressed and then prioritise them. Answering the questions will help managers to identify priorities for action.

Where do we want to be? (Goals & Objectives) Goals & objectives should be SMART Specific Measurable Achievable Realistic Time-bound In order for the goals & objectives to drive the strategy and to achieve tangible results, they should be SMART – that is, Specific, Measurable, Achievable, Realistic & Timebound.

Developing the Action Plan#1 (How Are We Going To Get There Developing the Action Plan#1 (How Are We Going To Get There?) Action Points Identify tasks related to each of the goals and objectives:- Specify timescales Specify resources required Specify responsibility for action(s) Quantify resources required & produce a business case to secure additional resources if necessary Each goal and objective will require a number of tasks in order for it to be achieved. Identifying these tasks will enable managers to assess the requisite timescales, quantify resources and determine who should be responsible for accomplishing the tasks. Where additional resources will be required a business case should be developed to secure them.

Developing the Action Plan (How Will We Know What Progress We Are Making?) Monitoring Criteria Determine monitoring criteria & timescales:- Specify how progress will be monitored and when Specify how progress will be reported Schedule monitoring meetings aligned with the timescales & milestones in the strategic plan In order to assess progress towards goals and objectives monitoring criteria should be determined and also the progress reporting mechanism. Monitoring meetings should be scheduled and aligned with timescales and milestones in the strategic plan.

The Health Records Management Strategy – Making it Happen The strategy should:- Contain a realistic action plan with achievable milestones and timescales for implementation; Identify resources required to achieve the plan; Identify possible risks, which may jeopardise the plan; Have regular reviews of progress built in to it. A Health Records Management Strategy is not just a document it is a means of effecting necessary, planned change in a managed way. The Strategy should contain a realistic action plan with achievable milestones and timescales for implementation. The plan should be appropriately resourced if it is to be achievable, both financially and in terms of human resources. If it is not realistic and achievable the strategy will not be successful. Possible risks, which may jeopardise the plan should be identified as soon as possible so that actions can be taken to minimise or eliminate those risks systematically. There should be regular reviews of progress built into the plan so that progress can be monitored and any risks kept under review.

Keeping The Strategy Under Review Review the strategy annually Maintain close links with the IM&T & corporate records management strategies Maintain close links with the IGT assessment process In the rapidly changing environment of today’s NHS and the imminent implementation of Electronic Records of all types, including NHS CRS, the Health Records Management Strategy should be reviewed annually and on-going close links should be maintained with the IM&T and Corporate Records Management Strategies & the Information Governance Toolkit assessment process

Raising awareness of Health Records Management – Why? To ensure that everyone knows who has the lead role for records management in the organisation To ensure that all members of staff understand their personal responsibilities in respect of health records management To ensure that issues and progress on health records management are routinely fed back to the Board In order for the Health Records Service to be effective and efficient it is essential that all members of staff in the organisation understand who has the lead role for health records management and that they have personal responsibilities in respect of health records management. It is also crucial that progress on health records management issues are routinely fed back to the organisation’s Board.

Further Guidance and useful links Records Management NHS Code of Practice DH: Records Management NHS Code of Practice Information Governance Toolkit www.igt.connectingforhealth.nhs.uk/ Records Management Roadmap www.connectingforhealth.nhs.uk/infogov/records NHS IG Policy Team website (Find out more about IG) www.connectingforhealth.nhs.uk/infogov Department of Health website www.dh.gov.uk/en/Home Here are some sources of further guidance and information.