Circulation Under the Public Records Act (1958) all NHS employees are responsible for any records that they create or use in the course of their duties. Therefore any records created by an employee working for the Heart of England NHS Foundation Trust are public records and may be subject to both legal and professional obligations. Accordingly, this Policy applies to all staff employed by the Heart of England NHS Foundation Trust with responsibilities for records management - including temporary, locum and contract staff. Scope This policy applies to NHS records of all types regardless of the media on which they are held. The range of records includes: patient health records (electronic or paper based for all specialities) records of private patients seen on NHS premises Accident & Emergency, birth and all other registers theatre registers and minor operations (and other related ) registers administrative records (including, for example, personnel, estates, financial and accounting records; associated with complaint handling) X-Ray and imaging reports, outputs and images photographs, slides and other images microform (i.e. microfiche/microfilm) audio and video tapes, CD-ROM etc e-mails computerised records scanned records. Definitions For the purpose of this policy, Records are defined as ‘information created, received and maintained by the Trust or a person working for the Trust, in pursuance of legal obligations, or in the transaction of business’ (BS ISO 15489.1). An NHS Record ‘is anything which contains information (in any media) which has been created or gathered as a result of any aspect of the work of Trust employees’. Records Management is the field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposal of records, including processes for capturing and maintaining evidence of, and information about, business activities and transactions in the form of records’. The term Record Life Cycle describes the life of a record through the following stages: creation and storage of records tracking and retrieval of records access to and disclosure of records transfer of records appraisal of records retention and disposal of records. Information is a corporate asset. The Trust’s records are important sources of administrative, clinical, evidential and historical information. They are vital to the Trust to support its current and
Attachment 2: Records Management Lifecycle Mapped to Trust Policies, Approving Committee and Monitoring/Audit Arrangements. Section Lifecycle Stage Trust Policy Approving Committee Monitoring and 7.1 Creation of records Patient Administration Policies and Procedures Medical Records - Duplicate records audit Record Keeping in Healthcare Records Policy Information Governance -Annual rolling programme of by safety and Governance, which includes case note filing Locally Managed Records Procedure Information Governance - Annual review of the register 7.2 Storage of records Information Security and Risk Management Policy ICT -Annual audit of key information assets Retention and Disposal of Records Policy and Procedure Information Governance Corporate Records: -FOI Procedure -Annual Information Governance Toolkit Risk Management Standards Healthcare Records: - Annual review Locally Managed Records Procedure Information Governance - Annual review of register 7.3 Tracking and Retrieval of records Case Note Tracking Policy Medical Records Healthcare Records -Incident eports generated daily -Bi-annual KPI report (Operational Directortes) - Bi-annual review of risk register 7.4 Access to and Disclosure of records Confidentiality Policy and Procedure Information Governance - Confidential exceptions Access to Health Records Policy ICT - KPIs collated by Medical Records Department monthly - Information Governance Toolkit Annual Review Freedom of Information Policy and Procedure for Processing Requests for Information Information Governance - Reports to Information Governance Committee - Information Governance Toolkit 7.5 Transfer of records Procedure for Establishing and Maintaining a Safe Haven Information Governance -Exception Reports (Incidents) -Information Flow Mapping Report Information Governance Toolkit 7.6 Appraisal of records Retention and Disposal of Records Policy and Procedure Information Governance See 7.3