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Health Records ManagementPractitioner
Information Governance Policy TeamNHS Connecting for Health
Key Learning Points
1. Responsibilities for health records2. Record Lifecycle Management3. Auditing current health records practices & procedures4. Undertaking an records inventory survey of existing
health records systems5. Drafting/maintaining the organisation’s health records
management policy6. Drafting/maintaining the organisation’s health records
management strategy & associated action plan7. Raising awareness of the importance of health records
management throughout your organisation
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
Record Lifecycle Management
Create Use Retention DisposalAppraisal
Clo
se R
eco
rd
Be aware ControlMonitor
Information RequestsInformation Requests
NHS records may be subject to NHS records may be subject to information requestsinformation requests
Health Records Policies & Procedures
Procedure Policy and Procedure manual
Key management toolBasis for specific training
Auditing Health Records Policies & Procedures – The Audit Cycle
The audit cycle
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.
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
Distributing & Completing the inventory
Distributing & Completing the Inventory Forms
Aggregating the Inventory Form
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
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
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
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
Aims of a Health Record Management Policy
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
To ensure that health records:
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
Aims of the Records Management Strategy
Responsibility and accountability Record quality Management Security Access Audit Training
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.
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
The Planning Cycle
1. Where are we now?(Position Statement)
2. Where do we want to be?(Goals & Objectives)
3. How are we going to get there
& how will we know what progress
We are making?(Action Points
& Monitoring Criteria)
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;
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.
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?
Where do we want to be? (Goals & Objectives)
Goals & objectives should be SMART SpecificMeasurableAchievableRealisticTime-bound
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
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
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.
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
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
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
Roadmapwww.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