Clinical Records Management Policy
Date of Implementation:
December 2011
Date of Next Review:
December 2014
Version No:
1.1
Approved at:
IG Committee
Originator:
Information Governance Manager
Lead Director:
Senior Information Risk Owner (SIRO)
Contents Page
1
Introduction ....................................................................................................... 4
2
Definitions ......................................................................................................... 4
3
Scope ................................................................................................................. 4
4
Roles and Responsibilities .............................................................................. 5
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
5
Chief Executive ...................................................................................................... 5
Caldicott Guardian ................................................................................................. 5
Medical Director ..................................................................................................... 5
Medical Records Committee .................................................................................. 5
Head of Performance & Planning ........................................................................... 6
Information Governance Manager / Information Governance Committee ............... 6
Medical Records Manager...................................................................................... 6
Executive/Clinical Directors, General Managers ..................................................... 6
Service Managers, Assistant Service Managers and Departmental Heads ............ 6
All Staff................................................................................................................... 6
Legal Obligations .............................................................................................. 6
5.1
5.2
5.3
6
Data Protection Act (DPA) 1998 ............................................................................. 6
NHS Confidentiality Code of Practice April 2007 .................................................... 7
The Caldicott Principles .......................................................................................... 7
Professional Obligations/Standards ............................................................... 7
6.1
6.2
6.3
7
Professional Obligations ......................................................................................... 7
NHSLA Risk Management Standards for Acute Trusts........................................... 8
NHS Number .......................................................................................................... 8
Unified Medical Record .................................................................................... 9
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
8
Trust Medical Record ............................................................................................. 9
Emergency Department Record ............................................................................. 9
Genito Urinary Medicine (GUM) ........................................................................... 10
Maternity Record .................................................................................................. 10
Nursing Records .................................................................................................. 11
Pathology Records ............................................................................................... 11
Private Patients .................................................................................................... 11
Radiology Records ............................................................................................... 11
Research Records ............................................................................................... 12
Therapies – Occupational Therapy....................................................................... 12
Therapies - Physiotherapy Records ..................................................................... 12
Allied Health Professional Records (AHP) ............................................................ 13
Record Information Quality Assurance ......................................................... 13
9
Record Creation .............................................................................................. 13
9.1
9.2
10
10.1
10.2
10.3
10.4
10.5
10.6
10.7
Clinical Record Creation ....................................................................................... 13
Creation of Temporary Medical Records .............................................................. 14
Record Management ................................................................................... 14
Allergy Recording ................................................................................................. 14
Use of stickers on the front of Trust Medical Records........................................... 15
Special Needs ...................................................................................................... 15
Copying Letters to Patients .................................................................................. 15
Advance Healthcare Decisions ............................................................................. 15
Medical Records Volumes .................................................................................... 15
Maintenance of Medical Records ......................................................................... 16
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11
11.1
11.2
11.3
11.4
11.5
12
12.1
12.2
12.3
12.4
13
13.1
13.2
13.3
14
14.1
14.2
14.3
15
15.1
16
16.1
17
17.1
Records Storage .......................................................................................... 16
Clinical Record Storage........................................................................................ 16
Medical Records Library....................................................................................... 16
Storage of Medical Record outside of Medical Record Library ............................. 16
Storage of Medical Records on the wards ............................................................ 17
Trust Off-site Storage ........................................................................................... 17
Records Tracking / Transportation ............................................................ 17
Tracking Medical Records .................................................................................... 17
Transportation of Clinical Records within the Frimley Park Site ............................ 18
Transportation of Clinical Records off site ............................................................ 18
Removal of a clinical record from the Trust Premises ........................................... 19
Record Disclosure ....................................................................................... 19
Internal Requests for Medical Records Required for Clinical Care ....................... 19
Release of Medical Records to Other NHS Providers........................................... 19
Release of Medical Records to a Third Party........................................................ 20
Records Retention....................................................................................... 20
Clinical Record Retention ..................................................................................... 20
Microfilmed Records............................................................................................. 21
Scanned Records................................................................................................. 21
Records Destruction ................................................................................... 21
Clinical Record Destruction .................................................................................. 21
Record Disposal .......................................................................................... 22
Clinical Record Disposal ...................................................................................... 22
Monitoring of Policy .................................................................................... 22
Medical Records Availability ................................................................................. 22
18
Breaches of policy....................................................................................... 22
19
Training ........................................................................................................ 22
20
Review .......................................................................................................... 23
21
Equality Impact Assessment ...................................................................... 23
Appendix 1 - Clinical Records Retention Schedule ............................................ 23
Clinical Records Retention Schedule .............................................................................. 25
Pharmacy Retention Schedule ........................................................................................ 28
X-Ray Retention Schedule .............................................................................................. 28
Appendix 2 – Trust Clinical Electronic Systems ................................................. 29
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1
Introduction
1.1.1
Records Management is the process by which an organisation
manages all the aspects of records whether internally or externally
generated and in any format or media type, from their creation, all the
way through their lifecycle to their eventual disposal.
1.1.2
The Records Management: NHS Code of Practice has been published
by the Department of Health as a guide to the required standards of
practice in the management of records for those who work within or
under contract to NHS organisations in England. It is based on current
legal requirements and professional best practice.
1.1.3
The Trust’s records are its clinical memory, providing evidence of
actions and decisions relating to patient care and representing a vital
asset to support the treatment of patients. Clinical records support and
protect the interests of the Trust and the rights of patients, staff and
members of the public.
1.1.4
This policy determines the standards which must be followed when
handling and dealing with any Trust Clinical record.
1.1.5
This Clinical Records policy should be read in conjunction with the
Trust’s Records Management Strategy and the Trust’s Non-Clinical
Records Policy.
2
Definitions
2.1.1
A Record is defined as anything which contains information (in any
medium) that has been created or gathered as a result of any aspect of
the work of NHS employees, including (but not limited to) bank, agency
and locum staff; students; voluntary staff and trainees on temporary
placements.
2.1.2
A Clinical Record is defined as ‘any record which consists of
information relating to the physical or mental health or condition of an
individual and has been made by or on behalf of a health professional in
connection with the care of that individual’.
3
Scope
3.1.1
This policy applies to all Trust Clinical records, both manual and
computerised including joint health and social care records.
3.1.2
The main principles of this policy are:
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it relates to all clinical records held in any format by the Trust;
it applies to information in paper and other physical forms, e.g. electronic,
microfilm, negatives, photographs, audio or video recordings and other assets;
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it relates to the 5 distinct phases in the life of information; creation, retention,
maintenance, use and disposal;
to set out the Trust’s commitment to create, keep and manage clinical records,
including electronic records which document the treatment provided to patients.
to define a structure for the Trust to ensure adequate clinical records are
maintained, managed and controlled and comply with legal, operational and
information needs.
3.1.3
Records can be created by anyone working within or on behalf of the
Trust. This includes, but is not limited to, employees, agents,
contractors and volunteers in any capacity.
3.1.4
This policy sets out a framework within which the staff responsible for
managing the Trust’s clinical records can develop specific policies and
procedures to ensure that all clinical records are managed and
controlled effectively and at best value commensurate with legal,
operational and information needs.
4
Roles and Responsibilities
4.1
Chief Executive
4.1.1
The Chief Executive has overall responsibility for records management
in the Trust. As accountable officer he is responsible for the
management of the Trust and for ensuring appropriate mechanisms are
in place to support service delivery and continuity. Records
management is key to this as it will ensure appropriate, accurate
information is available as required.
4.1.2
The Chief Executive has a particular responsibility for ensuring that the
Trust corporately meets its legal responsibilities and for the adoption of
internal and external governance requirements.
4.2
4.2.1
4.3
4.3.1
4.4
4.4.1
Caldicott Guardian
The Trust’s Caldicott Guardian has a particular responsibility for
reflecting patients’ interests regarding the use of patient identifiable
information. He is responsible for ensuring patient identifiable
information is shared in an appropriate and secure manner.
Medical Director
The Medical Director has Executive responsibility for the management
of Trust Clinical Records.
Medical Records Committee
Day to day management of the Trust’s medical records is undertaken by
the Medical Records committee, which is chaired by a senior clinician.
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4.5
4.5.1
4.6
4.6.1
4.7
4.7.1
4.8
4.8.1
4.9
4.9.1
4.10
Head of Performance & Planning
The Head of Performance & Planning has the responsibility for the dayto-day management of the Trust’s Medical Records.
Information Governance Manager / Information Governance Committee
The Trust’s Information Governance Manager/Committee is responsible
for ensuring this policy is implemented through the implementation of a
Records Management Strategy, and that the records management
systems and processes are developed, co-ordinated and monitored.
Medical Records Manager
The Medical Records Manager is responsible for the overall
development and maintenance of the Trust’s medical records
management policies and their implementation throughout the Trust, in
particular for drawing up guidance for good medical records
management practice and promoting compliance with this policy in such
a way as to ensure the easy, appropriate and timely retrieval of patient
information.
Executive/Clinical Directors, General Managers
Executive/Clinical Directors and General Managers are responsible for
ensuring that departmental policies and procedures relating to the
management of their clinical records comply with this Policy and that
risks associated with their clinical record usage are managed and
controlled.
Service Managers, Assistant Service Managers and Departmental
Heads
Service Managers, Assistant Service Managers and Departmental
Heads are responsible for ensuring that staff within their Department
receive training on this policy and their own departmental clinical
records procedures to ensure clinical records management and
associated risks are controlled.
All Staff
4.10.1 All Trust staff, whether clinical or administrative, who create, receive
and use clinical records have records management responsibilities. In
particular, all staff must ensure that they maintain accurate and
available clinical records for patients and ensure those records are
managed in line with this policy and with any guidance subsequently
produced.
5
5.1
5.1.1
Legal Obligations
Data Protection Act (DPA) 1998
The Data Protection Act regulates the processing of personal data, held
manually and on computer. It applies to all personal information; not
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just health records. Personal data is defined as data relating to a living
individual that enables him/her to be identified either from that data
alone or in conjunction with other information in the data controller’s
possession. It therefore includes such items as an individual’s name,
address, age, race, religion, gender and physical, mental or sexual
health.
5.1.2
The Act contains 3 key strands:
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
5.1.3
Notification by a data controller to the Information Commissioner
Compliance with the 8 data protection principles
Observing the rights of data subjects
Clinical Records management staff have a key role to play in ensuring
that records can be located, retrieved and supplied in a timely manner.
5.2
NHS Confidentiality Code of Practice April 2007
5.2.1
This Code of Practice provides guidance to the NHS and related
organisations on the handling of confidential patient information across
the NHS. Patient information is held under legal and ethical obligations
of confidentiality. Information provided in confidence must not be used
or disclosed in a form that might identify a patient without his or her
consent.
5.2.2
The Confidentiality Code of Practice describes a Confidentiality Model
which has 4 key requirements:
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5.3
5.3.1
The Caldicott Principles
The 6 Caldicott Principles must be observed when disclosing
confidential patient information to any other person either working for
the Trust or for another healthcare provider:
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6
Justify the purpose
Do not use patient identifiable information unless absolutely necessary
Use the minimum necessary patient identifiable information
Access to patient identifiable information must be on a strict need to know basis
Everyone must be aware of their responsibilities
Everyone must understand and comply with the law.
Professional Obligations/Standards
6.1
6.1.1
Protect – look after the patient’s information
Inform – ensure patients are aware of how their information is used
Provide Choice – allow patients to decide whether their information can be
disclosed or used in particular ways
Improve – always look for better ways to protect, inform and provide Choice
Professional Obligations
All Trust Clinical Records must be a legible record which:



Enables the patient to receive effective continuing care
Enables the healthcare team to communicate effectively
Enables the patient to be identified without risk of error
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

Facilitates the collection of data for research, education and audit
Can be used in legal proceedings
6.1.2
The Trust has comprehensive systems in place for the access, storage,
retrieval, usage, retention and destruction of all Trust Clinical records.
6.1.3
Clinical Record keeping standards are monitored through the clinical
audit process.
6.2
NHSLA Risk Management Standards for Acute Trusts
6.2.1
This policy must ensure compliance with the NHSLA Risk Management
Standards for Acute Trusts.
6.2.2
The original standards of the Clinical Negligence Scheme for Trusts
continue to be applied to clinical records management, namely:
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6.3
6.3.1
There is a unified medical record which all specialties use
Records are bound and stored so that loss of documents and traces are
minimised for inpatients and outpatients
There are clear instructions in the medical record regarding the filing of
documents
Operation notes, care pathways and other key procedures are readily
identifiable
Machine produced medical records are securely stored and use a method that
minimises deterioration to ensure availability during the entire retention period
Storage arrangements allow retrieval on a 24 hour/7 day basis
There is continuous multi-professional clinical audit of record keeping
standards, including high risk services
There is a mechanism for retaining certain records which must not be destroyed
The medical record contains a designated place for the recording of
hypersensitivity reactions and other information (e.g. Special Needs) relevant to
all healthcare professionals
A&E records are contained within the main record for patients who are
subsequently admitted
There is a system for ensuring that the GP is sent a copy of the A&E record
Nursing, medical and other records (e.g. physiotherapy notes, obstetric notes),
are filed together or referenced when the patient is discharged
There is a system for measuring efficiency in the recovery of records for
inpatients and outpatients
An author of an entry in a medical record is clearly and easily identifiable
NHS Number
The NHS number is the unique identifier for all patient records and is a
component of NHS CFH. Use of the NHS number will allow linkage of
patient records across systems and organisations. It is envisaged that
record linkage will improve effectiveness and efficiency of clinical care
to patients and support the concept of a lifelong record. The Trust is
required to ensure all clinical systems contain the NHS number and
each system fully adopts the NHS Number in order to be compliant with
the National NHS Number Information Standard.
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7
Unified Medical Record
7.1
7.1.1
Trust Medical Record
A Trust medical record is created to ensure clinical information relating
to a patient is available at the point of need within the Trust. The
purpose of a medical record is:
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7.1.2
Whilst the Trust aims to operate a unified medical record for patient
care, with all specialty records held in a single Trust record, some
departments within the Trust create and manage their own clinical
record. The clinical records in use across the Trust are:
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7.1.3
7.2.1
Medical
Emergency Department
GUM
Maternity
Nursing Records
Pathology
Private Patients
Radiology
Therapies - Occupational & Physiotherapy
The Trust has one medical record which contains the following clinical
information:
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7.2
To support the care process and continuity of care.
To support day-to-day business that underpins delivery of care.
To support evidence based practice.
To support sound administrative and managerial decision-making.
To meet legal requirements, including requests from service users
To assist clinical and other audits.
To support improvements in clinical effectiveness through research and also to
support archival functions by taking account of the historical importance of
material and the needs of future research.
Admission forms
Correspondence
Consent forms/ Anaesthetics & Recovery
Investigation results
ECG Cardiac
Ophthalmology
Charts- drug sheets – nursing records
Therapies – inpatient Physiotherapy – OT
Care Pathways
CPA/Supervision Register (Psychiatric)
Clinic Notes
Emergency Department Record
When a patient attends the Trust’s Emergency Department a record will
be created on the department’s computer system (Symphony) detailing
the care and treatment provided to the patient.
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7.2.2
On admission of a patient via the Emergency Department a copy of the
Emergency Record is filed in the clinical note section of the Trust
Medical Record for continuity of care and accompanies the patient to
the admitting ward.
7.2.3
Where a patient is not admitted into hospital, a separate emergency
record is held by the Trust.
7.2.4
The Emergency Department sends a Discharge Summary of the
patient’s attendance to the patient’s General Practitioner (GP) within 24
hours. The Discharge Summary details:
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attendance date
presenting complaint
investigations
diagnosis
treatment and follow-up
7.2.5
Following the implementation of the Symphony system in 2011 the
Trust ceased creating manual casualty cards. Old casualty cards are
stored at the Trust’s off-site storage facility – CDC - for their defined
retention period.
7.2.6
Symphony is fed from the Trust’s Patient Administration System (PAS)
– thereby sharing the Trust PMI (Patient Master Index).
7.3
Genito Urinary Medicine (GUM)
7.3.1
When a patient attends the Trust’s GUM clinic a separate record will be
created for the patient detailing the treatment provided.
7.3.2
A copy of the record is held in the GUM department and is not merged
into the Trust’s Medical Record. A unique number is allocated to
patients which is not obtained from the Trust’s PAS.
7.3.3
The GUM Records are stored within the GUM department for their
defined retention period.
7.4
Maternity Record
7.4.1
Maternity patients have hand-held ante-natal records for the duration of
their pregnancy. Maternity records are contained in a single booklet
comprising ante-natal, labour and post-natal records. Investigation
results will be filed onto the maternity mount sheet in the handheld
record.
7.4.2
During the patient’s pregnancy the Trust’s medical record is held in the
Ante-natal Department and is available at all consultations.
Cardiotocograph (CTG) results are filed into the standard brown re-
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sealable envelope available in the Obstetric Department. At the end of
the Patient’s pregnancy their ante-natal records will be amalgamated
into the main medical record.
7.5
Nursing Records
7.5.1
Nursing records form part of the main medical record and are filed
within the main medical record. Whilst a patient is an in-patient, nursing
records will be held at the bedside for reference and recording
purposes. On patient transfer, nursing records will be securely
transported together with the main medical record so that these are
easily re-utilised by the receiving ward.
7.5.2
When a patient transfer is planned, observation charts, fluid balance
charts (not currently required as part of on-going clinical management)
and investigation results will be secured within the main medical record.
7.6
7.6.1
7.7
7.7.1
7.8
Pathology Records
Request forms for patients are held in the pathology department
detailing the tests requested for each patient.
Private Patients
When a patient attends the Trust’s private patient suite the main
medical record will be used to record a summary of treatment provided
to the patient. More detailed information relating to the patient’s care
and treatment is held by the consultant in his private patient
records/files.
Radiology Records
7.8.1
Radiology records are managed and stored by the Trust’s radiology
department.
7.8.2
The Trust implemented Agfa Picture Archiving Computer System
(PACS) in 2004. PACS is linked to the Radiology Information System
(RIS) which is fed from the Trust’s Patient Administration System (PAS)
– thereby sharing the Trust PMI.
7.8.3
PACS images are distributed across the Trust wide network and
displayed using a web browser.
7.8.4
Radiology Reports are stored on RIS and are also available as
additional information in PACS. Information from RIS such as requests,
appointments and verified Radiology reports are sent to PAS. Radiology
reports appear on the web browser once they are validated (checked)
by the author.
7.8.5
Radiology reports are also distributed in paper copy to all referrers
including GP’s.
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7.8.6
Following the implementation of the PACS system in 2004 the Trust
ceased creating manual x-ray films. There are no manual x-rays films
stored in the Trust. Old X-ray films are stored at the Trust’s off-site
storage facility – Overs - for their defined retention period - 3yrs plus
current year except paediatric images that are kept until the patient is
21. Images that have 'do not destroy' stickers that are kept indefinitely.
7.8.7
Following the implementation of electronic mammograms images in
August 2007, the Trust ceased creating manual mammograms. There
are no manual mammograms stored in the Trust. Old mammogram
films are stored at the Trust’s off-site storage facility – Overs - for their
defined retention period. Mammograms are stored for five years and
when the patient re-attends the 5 year clock begins again.
7.9
Research Records
Where a patient has consented to participate in a clinical trial/research
project, a separate file for the patient will be created and stored by the
Principal investigator.
7.9.2 A note is placed in the patient’s medical record indicating the patient is
part of a research project. All medical records belonging to patients
enrolled into clinical trials prospectively will be labelled and contain a
section for the storage of clinical information relevant to patient’s trial
involvement.
7.9.1
7.10
Therapies – Occupational Therapy
7.10.1 When a patient is treated by Occupational Therapy staff a separate
electronic clinical record is created for them. Following the
implementation of the Tiara system in 2009 the Trust ceased creating
manual Occupational Therapy records. Only child Occupational
Therapy records are stored on site. Adult Occupational Therapy
Records are stored at the Trust’s off-site storage facility – CDC - for
their defined retention period.
7.10.2 Tiara is fed from the Trust’s Patient Administration System (PAS) –
thereby sharing the Trust PMI.
7.11
Therapies - Physiotherapy Records
7.11.1 When a patient is treated by the Physiotherapy department, an
outpatient physiotherapy referral card is created for them. Clinical
information relating to their outpatient treatment is recorded on the
physiotherapy card. Physiotherapy treatment provided to an inpatient is
recorded in the patient’s medical record.
7.11.2 Once the patient has been discharged from the department, the
outpatient physiotherapy card is stored for a short period of time within
the Physiotherapy department before being transferred off site to the
Trust’s off-site storage facility – CDC - for their defined retention period.
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7.11.3 Tiara is fed from the Trust’s Patient Administration System (PAS) –
thereby sharing the Trust PMI – patient master index.
7.12
Allied Health Professional Records (AHP)
7.12.1 Allied Health Professionals write directly into the main medical record
for inpatient and some Outpatient consultations. Any other
documentation is filed within the Medical Record on discharge.
7.12.2 Where an AHP has undertaken an assessment in the patient’s home
whilst the patient is an inpatient, this documentation is filed within the
main medical record. If care continues on an outpatient basis, regular
reports must be made and filed in the medical record, particularly if
there is a change of treatment or on discharge. Reports are addressed
to consultants (or other relevant clinical staff) and are filed in the
medical record by Directorate clerical staff.
8
Record Information Quality Assurance
8.1.1
Good quality information stored in clinical records enable staff to
undertake their roles and responsibilities effectively as well as provide
authentication of the records so that the evidence derived from them is
shown to be credible and authoritative.
8.1.2
When managing its clinical records, the Trust must ensure that the
clinical record being created is of high quality. All Clinical records must:
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9
9.1
9.1.1
Be factual, consistent and accurate
Be written in black ink
Be written as soon as possible after an event has occurred, providing current
information on the care and condition of the service user
Be written clearly, legibly and in such a manner that they cannot be erased
Have errors corrected by a single line and any such corrections signed and
dated by the person making the amendment. Erasers, liquid paper, or any other
obliterating agents should not be used
Be accurately dated, timed and signed with the signature being printed
alongside the first entry
Contain as few abbreviations or jargon as possible
Be consecutive
Be bound and stored in accordance with Trust’s procedures ensuring that the
likelihood of loss of documentation is minimised
Record Creation
Clinical Record Creation
Records of all clinical treatment provided to a patient must be recorded
within the patient’s medical record or the applicable electronic clinical
system (see appendix 2 for the list of the Trust’s Clinical systems) to
enable members of staff and their successors to continue the care and
treatment of a patient.
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9.1.2
A number of departments are able to create new Medical Records for
each new patient e.g. Emergency Department, Parkside. The Trust’s
medical records are pre-printed with Trust hospital numbers. Upon
creation of a new patient record the hospital number is entered into the
PAS. At the point of creating a medical record a year sticker is placed
on the side of the medical record folder to assist with the
destruction/retention of the record.
9.1.3
Where a patient record has been stored off site for longer than 5 years
and the patient re-attends the Hospital, the patient’s old medical folder
will be recalled from the Trust’s off-site storage and a new record
created for the patient with a new hospital number.
9.1.4
Where a clinical department creates a record for a patient they must
ensure this record can be linked to the patient’s main medical record.
Each clinical record department must develop and maintain procedures
relating to the creation of their clinical records.
9.1.5
At the point of creating a clinical record consideration must be given to
the lifecycle of the record and its ultimate destruction, particularly where
the record is in electronic format.
9.2
Creation of Temporary Medical Records
9.2.1
If a patient’s medical record cannot be located, a temporary record will
be created for the patient. A set of temporary medical records is only
created with approval from the Medical Records Manager or their
deputy.
9.2.2
The temporary medical record for a patient has a red cover. The
Medical Records department will monitor all temporary medical records
to search and locate the original medical record.
9.2.3
Where the original medical record has not been found within 2 years of
the temporary medical record being created, the temporary medical
record will become the patient’s main health record.
9.2.4
The Medical Record Department manages and maintains a missing
record log.
9.2.5
When temporary medical records are created this is indicated in the
Loan Comment field on the Trust PAS.
10
Record Management
10.1
Allergy Recording
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10.1.1 Allergies & Adverse Drug Reaction form part of the inside cover in the
medical records from 2006. Medical Records prior to 2006 must have
the documentation placed on front inside cover in all instances.
10.1.2 Allergies must be recorded on the inside front cover sheet. This
instruction is printed in the front of new medical records from 2006. Prior
to 2006, details were recorded on the “Patient Alert” sheet in the front of
the medical record.
10.2
Use of stickers on the front of Trust Medical Records
10.2.1 Following approval of the Trust’s Caldicott Guardian, stickers may be
placed on the front of the Trust’s medical records. The following
stickers have been approved to be placed on the front of a medical
record:



10.3
Year sticker – indicating the year the patient was treated in the Trust to facilitate
the retention of the record
Butterfly sticker – indicating the patient has dementia
Special needs – Identify the patient has additional care requirements
Special Needs
10.3.1 Where a patient has a special need (e.g. interpreter, large print,
wheelchair) this must be recorded on the front sheet of the medical
records and a ‘special needs’ sticker placed on the front of the medical
record. The Trust PAS maintains a Special Needs Register which staff
must ensure is kept up to date.
10.4
Copying Letters to Patients
10.4.1 Patients will receive a copy of the letters sent to their GP and other
consultants relating to their care.
10.4.2 If the patient does not want to receive a copy of these letters this will be
recorded on the PAS in the “Medisec” section of the PAS. This allows
Medical Secretaries to see whether a copy of the letter needs to be sent
to the patient.
10.4.3 Results letters are generally not transmitted to patients as these may
contain information not discussed at consultation.
10.5
Advance Healthcare Decisions
10.5.1 Advance Healthcare Decisions (Living Wills) must be flagged on the
front sheet of the medical records from 2007. The Advance Decisions
must be filed behind the Patient Administration Sheet. Advance
decisions can be flagged in older records by the use of the stickers
available from Medical Records.
10.6
Medical Records Volumes
Clinical Records Policy
Page 15 of 29
Review Date: December 2011
10.6.1 Where a medical record becomes too large for easy day to day use, a
second medical record for the patient will be created. The latest volume
will be used when the patient attends the hospital unless specifically
requested by the treating clinician.
10.7
Maintenance of Medical Records
10.7.1 The maintenance of the Trust’s medical records is the responsibility of
all staff who make use of the record. This includes the correct filing of all
loose paperwork relating to the patients care and the volumising of a
record should it exceed the required size of 4cm..
11
11.1
Records Storage
Clinical Record Storage
11.1.1 All systems used to store Clinical records will ensure the information is
kept safe and secure from unauthorised access whilst allowing
maximum accessibility to the information commensurate with its
frequency of use.
11.1.2 All manual Clinical records will be kept in a secure environment and
access will be restricted to authorised personnel only.
11.2
Medical Records Library
11.2.1 A Patient’s medical record contains the majority of the clinical records
created by the Trust. This record is stored in the Trust’s Medical
Records library.
11.2.2 The Trust operates a closed library system, operated only by
designated staff, who are authorised to file and retrieve medical
records. Restricted access to the library ensures confidentiality and
security measures are in place and improves medical record availability.
11.2.3 Any member of staff requesting a medical record must be an authorised
Trust employee. Records requested on an urgent or routine basis will
be made available within agreed time limits, urgent requests being
acted upon immediately.
11.2.4 The Medical Record Library is open 24 hours per day 7 days per week,
including Bank Holidays, to support emergency retrievals, requests and
returns of the Trust’s medical records.
11.2.5 The Medical Records procedure manual details the process Medical
Records staff follow when retrieving Medical Records for staff from the
Trust’s Medical Record’s library.
11.3
Storage of Medical Record outside of Medical Record Library
Clinical Records Policy
Page 16 of 29
Review Date: December 2011
11.3.1 Where a Clinical record is stored outside of the Trust’s medical record
library the records must be stored in a logical order to enable quick and
easy retrieval of the medical record e.g. organised by date of clinic,
numerically, etc.
11.3.2 Medical Records must always be kept secure when left unattended to
prevent unauthorised access to the medical record e.g. stored in a
locked cupboard/room.
11.3.3 Where a medical record is not located in Trust’s medical record library,
the Emergency Department are able to retrieve the medical record from
the location in the hospital that they are tracked to. Master keys for
offices are available via the switchboard.
11.4
Storage of Medical Records on the wards
11.4.1 Medical Records will be stored on the ward either in a medical record
trolley behind the Ward desk, or for surgical patients at the end of the
patient’s bed with their nursing notes.
11.5
Trust Off-site Storage
11.5.1 When discharged from the Trust the patient’s medical record will be
stored in the Medical Records library for 2 years before being sent to
the Trust’s off-site storage facility for their defined retention period.
11.5.2 The Trust’s off-site storage facility – CDC - is used to stored inactive
clinical records (Pharmacy, Occupational Therapy, Physiotherapy,
Emergency Department). Each department is responsible for ensuring
clinical records are stored in line with the Trust Off Site Storage
Procedures.
11.5.3 It is the responsibility of the off-site storage company to ensure that
security and confidentiality of all Trust clinical records and their
operational procedures are compliant with Principle 7 of the Data
Protection Act 1998.
11.5.4 Access to the clinical records will be restricted to personnel employed
by the off-site storage company. The clinical records will only be
accessed when a request is made for the record to be returned to the
Trust. This is done through either the Medical Records Department or
the Information Governance Department.
11.5.5 At no time will a clinical record be opened or read by any member of
staff employed by the off-site company.
12
12.1
Records Tracking / Transportation
Tracking Medical Records
Clinical Records Policy
Page 17 of 29
Review Date: December 2011
12.1.1 The Trust’s medical records are registered on the PAS. All record
transactions (i.e. movements) relating to a Trust medical records must
be recorded on the PAS within the “Casenote Tracking module”.
12.1.2 When a Medical Record leaves the Trust’s medical record library it must
be tracked to the location it is being moved to. Tracking the medical
records electronically records the movement of the medical record.
12.1.3 All movements of a medical record must be tracked on the PAS as soon
as possible and certainly within 15 minutes of the movement. The
history of previous medical record movements will be kept for the last
six movements.
12.1.4 When a record is moved it is the responsibility of the person in the current location to
track the record to its new location.
12.2
Transportation of Clinical Records within the Frimley Park Site
12.2.1 Medical Records being transported must be placed in sealed and
accurately addressed envelopes, marked Private & Confidential and
stating the name of the person to whom they are being sent (i.e. it is
insufficient to simply address them to a department or building).
12.2.2 When a patient is being transferred within the Hospital building from
department to department by a Trust member of staff (e.g. a porter) the
member of staff must carry the medical record.
12.2.3 When a patient is not escorted by a Trust member of staff the patient
could be asked to carry their medical records, providing they are in a
sealed envelope that is fully addressed to the department/ward the
patient is due to visit/attend.
12.2.4 Medical records must not be left unattended at any time (e.g. when
awaiting portering services).
12.3
Transportation of Clinical Records off site
12.3.1 Where medical records need to be transferred to another location to
support the Trust services (e.g. For outpatient appointments at off-site
clinics - Farnham, Fleet, Aldershot Centre For Health, Bracknell,
Skipton Hill, etc.), the transportation of medical records be must be
undertaken by Trust transport in sealed envelopes or, in the case of
bulk returns, in sealed bags/boxes.
12.3.2 Where medical records are being transferred to the Trust’s off-site
storage facility it is the responsibility of the off-site storage company to
ensure all records are securely transferred in full compliance with the
Data Protection Act 1998.
Clinical Records Policy
Page 18 of 29
Review Date: December 2011
12.3.3 Only where staff need to treat a patient outside of Trust premises (e.g.
at home, nursing home, provision of community services etc.), the
member of staff is permitted to transfer the patient’s medical record.
12.3.4 When staff are transporting a medical records they must ensure all
records are kept secure during transit (e.g. in the boot of a car and not
on a seat) and are not left in a car unattended overnight.
12.3.5 All medical records must be returned to the hospital as soon as
possible.
12.4
Removal of a clinical record from the Trust Premises
12.4.1 The Trust’s Medical record must not be removed from the Trust
premises by individual members of staff unless for approved business
use (i.e. outpatient appointment at an off-site location, care and
treatment of patient in the community, at their home).
12.4.2 Where staff have a need to take a medical record off site for a reason
other than those detailed above, they must obtain approval of the
Trust’s Medical records Manager or Deputy.
13
13.1
Record Disclosure
Internal Requests for Medical Records Required for Clinical Care
13.1.1 Internal requests for medical records from Trust staff must only be for
the purpose of clinical care. Requesters are required to state the
purpose for the loan of the record and Library staff will check this on
receipt.
13.1.2 Where a medical record needs to be accessed for the Trust’s
healthcare purposes (i.e. research, audit, complaints, litigation) records
must be requested following the appropriate Trust procedures.
13.2
Release of Medical Records to Other NHS Providers
13.2.1 On receipt of a request to release records to another hospital, patient
consent must be obtained.
13.2.2 It is essential that all requests to release medical records are obtained
in writing.
13.2.3 Requests from GP surgeries for results or discharge documentation
must be directed to the department that initiated the requested
information.
13.2.4 Only photocopies of the medical record can be released to another NHS
Provider, allowing retention of the original medical record by the Trust.
Clinical Records Policy
Page 19 of 29
Review Date: December 2011
Any exceptions to this procedure must be agreed with the Medical
Records Manager.
13.2.5 Any release of a medical record must be recorded within the casenote
tracking module on the PAS by the person responsible for sending the
medical record to the requested location/person.
13.3
Release of Medical Records to a Third Party
13.3.1 Where the Trust receives a request for patient information from a Third
Party (e.g. benefits office, police, insurance company, solicitor) it will
only be disclosed where the patient has consented to the release of
their information.
13.3.2 The release of patient information to third parties will be managed in full
compliance with the Data Protection Act 1998, Common Law Duty of
Confidentiality and Access to Health Records Act 1990.
14
14.1
Records Retention
Clinical Record Retention
14.1.1 All Clinical records must be retained for defined periods. This retention
period is calculated from the end of the calendar year following the last
entry in the record (e.g. manual file, computer record).
14.1.2 The Trust has adopted the retention periods set out in the Department
of Health Records Management: NHS Code of Practice. Appendix 1 of
this policy details the retention periods for all Trust clinical records.
14.1.3 Where a record type is not listed the Trust’s clinical managers will carry
out a risk assessment to decide how long the record is required to be
kept for. Attention will be paid to other retention periods for similar
record types combined with the risks and benefits of destroying or
maintaining the records for a prolonged period of time.
14.1.4 Once a retention period has been decided for a clinical record, this will
be approved by the Trust’s IG committee and incorporated within the
retention schedule detailed in Appendix 1 of this policy.
14.1.5 The retention schedule details the minimum retention period for each
type of clinical record. Clinical records (whatever the media) may be
retained for longer than the minimum period, however generally records
should not be retained for more than 30 years in accordance with the
Public Records Act 1958.
14.1.6 The Trust will develop procedures detailing how the Trust undertakes
an appraisal of its records. The appraisal process determines whether
records are worthy of permanent archival preservation.
Clinical Records Policy
Page 20 of 29
Review Date: December 2011
14.1.7 The Trust would undertake the appraisal process in conjunction with the
local approved Place of Deposit. This normally applies to a record
where a retention period in excess of 30 years is required (e.g. to be
preserved for historical purposes), or for any pre-1948 records. In these
cases, the National Archives will be consulted.
14.2
Microfilmed Records
14.2.1 Microfich is a permissible storage medium acceptable to the courts.
Microfilming standards were quality assured to ensure reconstruction of
the microfilmed record is possible.
14.2.2 The Trust’s Medical Record Department mircofiched inactive medical
records from 1992/3 until 2006. A register of all microfiched records is
held on a secure departmental database within the Medical Records
Library.
14.3
Scanned Records
14.3.1 The GUM department has scanned their clinical records to CD to
maintain the record for the required retention period, enabling the
manual records to be destroyed and providing much needed physical
storage for the active clinical record.
15
15.1
Records Destruction
Clinical Record Destruction
15.1.1 Clinical records (including copies) not selected for archival preservation
and which have reached the end of their life will be destroyed in a
secure manner. This will be undertaken either on site or by the Trust’s
off-site storage company.
15.1.2 In exceptional circumstances clinical records may require permanent
preservation – the clinician who is seeking to retain a record must gain
approval for permanent preservation from the Medical Director and, if
possible, consent from the Data Subject.
15.1.3 If the Caldicott Guardian is in agreement, the clinician must document
clearly the reason for permanent preservation clearly within the medical
record. Medical Records required for permanent preservation must be
clearly marked “FOR PERMANENT PRESERVATION” on the outside
front cover.
15.1.4 The destruction of records is an irreversible act. The normal destruction
method used by the Trust is shredding.
15.1.5 All removable magnetic or optical media containing clinical information
must be returned to the IT department for safe disposal. In addition,
Clinical Records Policy
Page 21 of 29
Review Date: December 2011
any IT equipment scheduled for disposal which contains non-removable
storage devices such as hard disk drives, must also be returned to the
IT department.
15.1.6 The hard disk must be formatted or rendered inoperable (e.g. physically
destroyed) and stored securely awaiting disposal by the same means
as removable media. In order to dispose of magnetic media, a secure
bonded media disposal facility must be employed and a full audit trail of
tapes and disks disposed should be maintained by the Informatics
Department.
16
Record Disposal
16.1
Clinical Record Disposal
16.1.1 All clinical records must be disposed of in line with the Trust’s
Confidential Waste Procedures.
17
Monitoring of Policy
17.1
Medical Records Availability
17.1.1 The following standards for Medical Record Availability have been
agreed:


Outpatient Clinic - 98% of medical record must be available at the start of the
clinic
Elective Admission -100% of medical records must be available on the ward at
the time of admission
17.1.2 Audits on the management of the Trust’s medical records are
undertaken by medical records staff on a regular basis including:

A Monthly snapshot of random areas showing compliance of tracking records.
To cover a selection of areas within the Trust including inpatient, outpatient and
non patient care areas.
17.1.3 Additional audits will be undertaken by the Medical Records department
as and when required to demonstrate compliance with this policy and
the Medical Records Procedure Manual.
17.1.4 Results of these audits will be reported to the Trust’s Medical Records
Committee and to the Trust Board through the SIRO report every 6
months.
18
Breaches of policy
18.1.1 Where it is identified a member of staff is not adhering to the guidelines
set out in this policy, the Trust reserves the right to take disciplinary
action.
19
Training
Clinical Records Policy
Page 22 of 29
Review Date: December 2011
19.1.1 Staff awareness of their individual responsibilities for the maintenance
and protection of the clinical records that they create, use or manage
will be raised through the Trust’s induction programme, team meetings,
Trust Briefings and other avenues as appropriate.
19.1.2 The training needs of staff in relation to clinical records management
will be identified so that training can be updated and reinforced as
necessary.
19.1.3 Managers will be responsible for ensuring that all their staff are aware of
the Trust’s Clinical Records Management Policy.
19.1.4 The Trust will provide general Records Management training as part of
its annual Information Governance Training.
19.1.5 All Trust staff will be made aware of their responsibilities for record-
keeping and record management through generic and specific training
programmes and guidance.
20
Review
20.1.1 This policy will be reviewed every three years (or sooner if new
legislation, codes of practice or national standards are introduced).
21
Equality Impact Assessment
21.1.1 The users of this policy will take into account their statutory duty to
promote equality and human rights and to act lawfully within current
equality legislation and guidance.
21.1.2 This policy has been equality impact assessed and has been shown to
have no adverse impact on any equality group.
21.1.3 The Trust will continue to monitor its effect and will assess again if
negative impact is identified or at the review date.
Appendix 1 - Clinical Records Retention Schedule
21.1.4 The coding within the schedules denotes the status of the type of record
and its retention period:


Note 1 = Where an organisation has an existing relationship with an approved
Place of Deposit, it should consult the Place of Deposit in the first instance.
Where there is no pre-existing relationship with a Place of Deposit,
organisations should consult The National Archives.
Note 2 = a previously existing record type (i.e. referenced in the previous
retention schedule dated March 2006) but where there has been a change to
the retention period following release of the updated Department of health
Records Management Code of Practice 2008.
Clinical Records Policy
Page 23 of 29
Review Date: December 2011
Clinical Records Policy
Page 24 of 29
Review Date: December 2011
Clinical Records Retention Schedule
Minimum Retention Period
Notes
From date of attendance relating to the
following specialities:
 Emergency Department
 Audiology
 Dental
 Endoscopy
 Ophthalmology
 Intensive Care Charts
 Oncology/Cancer
 Medical Illustrations
 Microfiche/Microfilm
 Occupational Therapy
 Sexual Health Records
 Physiotherapy
 Podiatry
 Ultrasound
Final
Action
Adult Record
8 years
Child Record
Retain until the patient’s 25th birthday
or 26th if young person was 17 at
conclusion of treatment, or 8 years
after death.
Admission Books
8 years
From last entry
Note 1
Angiography tapes and disks
8 years
From last date of treatment
Destroy
Audio tapes of calls
3 years
All relevant clinical information has been
transferred to Trust Medical Record
Destroy
Audit Trails (electronic records)
Until further notice
Birth Registers
2 years
Birth Notification
Retain until the patient’s 25th
birthday.
Blood Transfusion
30 years
From date of transfusion
Destroy
Breast Screening (Mammography)
9 years
After date of final attendance/death
Destroy
Mammography – Screen detected cancers,
interval cancers, interesting cases
Indefinitely
Destroy
Cervical Screening slides
10 years
Destroy
Chaplaincy records
2 years
Note 1
Clinical Records Policy
Page 25 of 29
Review Date: December 2011
Destroy
Destroy
Destroy
Lists are sent to General Register Office.
Note 1
Destroy
Clinical Records Retention Schedule
Minimum Retention Period
Notes
Final
Action
Clinical audit records
5 years
Clinical Trials (including Pharmacy records)
5 years
Clinical psychology
20 years
Note 2
Contraception records
8 years (in adults) or until 25th
birthday in a child (age 26 if entry
made when young person was 17)
Destroy
Counseling Records
20 years, 8 years after patient’s death
Note 2
Creutzfeldt‐Jakob Disease
30 years from date of diagnosis,
including deceased patients
Note 2
Death Certificates/ Registers
2 years
Destroy
Deceased Records
8 years
Except: CJD and transfusion.
Diaries
2 years
After end of year to which the diary relates.
Patient specific information must be
transferred to medical record.
Destroy
Discharge Books
8 years
After the last entry date
Note 1
Did Not Attend
2 years
After decision is made
Destroy
Donor Records
30 years
From date of post operation
Note 1
Duplicate Records
2 years
After decision to merge or unmerge
Destroy
Electrocardiogram (ECG) Records
7 years
Genetic Records
30 years
From last date of attendance
Note 1
GUM Adult Records
10 years
From last entry
Destroy
GUM Child Records (under 18)
8 years (in adults) or until 25th
birthday in a child (age 26 if entry
made when young person was 17).
Destroy
Infection Control Records
6 years
Destroy
Joint Replacement Records
10 years
Note 1
Clinical Records Policy
Page 26 of 29
Review Date: December 2011
Destroy
From closure of trial
Destroy
Note
Destroy
Clinical Records Retention Schedule
Minimum Retention Period
Notes
Mental Health Record
20 years
Mortuary registers
10 years
Note 1
Notifiable Diseases
6 years
Destroy
Operating Theatre Lists
4 years
Destroy
Operating Theatre Registers
8 years
Note 1
Oncology Records
30 years
Note 1
Outpatient Lists
2 years
Pathology Records
10 years
Post Mortem Records
30 years
Referral Letters
2 years
Destroy
Refrigeration and freezer charts
11 years
Destroy
Research Records
5 years
Smoking Cessation
2 years
Clinical Records Policy
Page 27 of 29
Review Date: December 2011
From last contact, or 8 years after death
Final
Action
After the year they relate
Destroy
Destroy
Destroy
Approval sought from Coroner to file in the
medical records
After conclusion of trial
Destroy
Destroy
Destroy
Pharmacy Retention Schedule
Minimum Retention Period
Requisitions
2 years
Registers and CDRBs
Extemporaneous preparation
worksheets
Aseptic worksheets (adult)
2 years
Notes
From last entry
Final
Action
Destroy
Destroy
13 years
Destroy
13 years
Destroy
Aseptic worksheets (Paediatric)
26 years
Destroy
External orders and delivery notes
2 years
Destroy
Prescriptions (inpatients)
2 years
Destroy
Prescriptions (outpatients)
2 years
Destroy
Destruction of CDs
7 years
Destroy
Ward Pharmacy Requests/Books
1 year
Destroy
X-Ray Retention Schedule
Minimum Retention Period
Notes
Final
Action
Adult
8 years
Destroy
Children
25 years
Until the child’s 25th Birthday
Destroy
Maternity
25 years
After birth of child
Destroy
Clinical Trials
15 years
After completion of treatment
Destroy
Litigation
10 years
After file is closed
Destroy
Mental Health
30 years
Destroy
Oncology
Clinical Records Policy
Retain
Page 28 of 29
Review Date: December 2011
Appendix 2 – Trust Clinical Electronic Systems
Daryl Gasson
Information
Helen Coe
Medicine, Eldery,
Outpatients and
Ian Fry
Diagnostic and Therapy
Services
Paul Bostock
Chris Ball
Surgical Services
Womens & Children
Information
Infocom
Reporting
system
Cardiology
Prismnet
Anticoagulant
RAID
Audiology
AuditBase
Childrens
Centre
Information
Ardentia
Data
Warehouse
Cardiology
XIMS
Anticoagulant
Coaguchek
XS plus
Cancer
Department
Somerset
Maternity
Information
CHKS Live
(Signpost)
Cardiology
Medcon
Microbiology
Kiestra
Cancer
Department/Re
search
IBIS-II
Maternity
Diabetic
Clinic
Diabeta3
Pathology
Sunquest ICE
Critical Care
(ICU)
Ward
Watcher
Pathology
Pathology
DART
MSoft
Endoscopy
Endoscopy
Pathology
Infection
Control
Endoscopy
Mirocam
Prescription
Pharmacy
Tracker
System
Pathology
B-Plan
Activity
Based
Costing
Software
Ophthalmology
Medisoft
A&E/MAU
Medex
Pathology
Radiance
Ophthalmology
Point of Care
A&E
Sympthony
Pathology
QCM3 Point
of Care
Sterile
Services
(HSDU)
SSDMan
??
IBS
Pathology
Medifact
Cytology
Results to
PCA
ENT
EncorePro2
PTS Online
Services
Cleric
Surgery
Orthoview
Radiology
PACS
Theatres
CareSuite
Radiology
Bbrad
Urology
Urodynamics
Radiology
RIS
Urology
Ezzee
Peezee
PAS
(Clinicom)/Pa
Trust-wide
tient Centre
GP Browser
4
GUM
Lilie System
Pharmacy
JAC
Medicines
Pharmacy Information
Databank
Clinical
Novacor
Investigaton
RTSoft
s
Clinical
Hypertensio
Investigaton
n
s
Clinical
Multiple
Investigaton
Sclerosis
s
Clinical
Breeze
Investigaton
Database
s
15
Pathology
Therapies
Clinical Records Policy
Winpath/
Ophthalmology
Ward Enquiry
Tiara
Pathology
TPath
Radiology
RIS Archive
Radiology
Radiology
NightHawk
CT Scanners
21
Page 29 of 29
Anaesethics
3di
Mike McSweene
Finance and
Contracting
IT
Euroking/C
TG
Monitoring
K2 Fetal
Monitoring
Training
System
EDTS
1
Maternity Colposcopy
Unisoft
Neo-Natal
Trackerscope Neo-Natal
Viewpoint
SEND
Neo-Natal Massinimo
7
Humphrey
Visual Field
Analyser
Optos
RotaTrack
17
Review Date: December 2011
Total
Number
of
Systems
65