Healthcare Records Policy and Procedures Manual Author(s) Matthew Hall – Information Governance Manager & Paula Gale – Head of Healthcare Records Version 3 Version Date May 2012 Implementation/approval Date September 2012 Review Date September 2013 Review Body Information Governance Committee Policy Reference Number 268/c/c/fi Table of Contents
Information Governance Policy Risk Management Strategy Incident Reporting and Serious Untoward Incident (SUI) Policy Information Lifecycle Policy Community Services Copying Letters to Service Users Data Encryption Guidelines Data Quality Policy E-mail Usage Policy Safe Haven Policy North East London Information Sharing Protocol EPR, RiO & other patient systems manuals, policies and procedures Equality Impact Assessment As part of its development, this policy and its impact on equality have been assessed in line with the Trust’s Policy Framework. The purpose of this assessment is to minimalise and if possible remove any disproportionate impact on employees on grounds of race, sex, disability, age sexual orientation or religious belief. No detriment was identified. Review and Monitoring This Policy should be kept under review in the light of changing circumstances and requirements. As a minimum it should be reviewed routinely every three years. If there are significant changes this should returned to the ratifying body for approval. The processes for monitoring compliance with this procedure are outlined in the table below: Measurable Policy Objective Monitoring/Audit Frequency of monitoring Responsibility for performing the monitoring Monitoring reported to which groups/committees, inc responsibility for reviewing action plans Process for tracking records Audit of tracking process, selection of tracked out records on EPR, records on wards, Community records Ongoing Head of Medical Records Information/Caldicott Committee Incident Reporting Interrogation of incident reporting database, Datix, to identify those incidents involving record keeping. These incidents include: Missing or lost patient records Mis-filed records Quarterly Information Governance Manager / Head of Healthcare Records Information Governance Committee
The above list is not exhausted Process for the creation of records Health Records Administration Audit Yearly Head of Medical Records Information/Caldicott Committee Record keeping meets acceptable standards Record Keeping Audit Yearly Head of Medical Records Information/Caldicott Committee Security and confidentiality of records Audit of Departments – check no PII left out on desks, locked filing cabinets, doors, codes are changed, fax machines Annual Plan Information Governance Manager / Head of Healthcare Records Information/Caldicott Committee Appendix A: Record Keeping Essential Elements Where there are local variations it is the responsibility of the healthcare professional to ensure that they are aware of and adhere to these variations. Essential Elements • All records must be kept on Trust authorised stationery. • The name of the person about whom the record is made must appear along with the NHS number Hospital number or any relevant reference numbers on each page. • Where health record sheets have not been pre-printed, patient labels will be used e.g. on all history sheets, Nursing Assessments and Diagnostic Test Results. • A clear and logical format must be used. • Only black ink should be used. • Judgmental or inferential statements are not recorded. • All entries must be signed with a signature not initials. A block capital of the name must appear with all signatures. • Accurately date and time every entry with day, month, year and 24 hour clock • A key should be shown where initials are used. • Records that have been written up contemporaneously cannot later be torn up or discarded. • No Record = No Contact, as the activity cannot be corroborated. • Should be free from any unknown abbreviations. Any abbreviations used must be in accordance with guidelines issued by the relevant professional bodies. • Left and right should always be written in full • Never use abbreviations for making derogatory comments about the patient • All document filing is the responsibility of the individual, service or department in possession of the case notes at the time of the episode concerned and need to ensure that all loose documents are affixed in the records prior to being returned to the Health Records library. In the event that the records are returned to the library before such