Clinical Records Management
Policy and Procedures
Policy and procedures on clinical records management
Page:
Page 1 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Recommended by
Quality Committee
Approved by
Board of Directors
Approval date
12.01.2015
Version number
4.1
Review date
January 2017
Responsible Director
Director of Quality
Responsible Manager (Sponsor)
Clinical Records Manager
For use by
All Trust employees
Policy and procedures on clinical records management
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Page 2 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
CHANGE RECORD FORM
Version
Date of
Change
Date of
release
Changed
by
Reason for change
X1
1 May
2007
1 May
2007
Y Cutler
Document Creation
X2
30 May
2007
30 May
2007
Y Cutler
Revised Draft to include service delivery feedback.
X3
2 July
2008
2 July
2008
Y Cutler
Amend contents in line with NHSLA
Requirements
X4
10 Nov
2008
10 Nov
2008
Y Cutler
Amend contents in line with NHSLA
Requirements
X5
10 June
2009
10 June
2009
Y Cutler
Amend ECG procedure 3.6
2.0
25 Aug
2010
25 Aug
2010
Y Cutler
3.0
May
2012
Y Cutler
4.0
Nov
2013
Y Cutler
Amended job titles, grammatical errors and contents in line with
NHSLA Requirements. NHSLA best practice template reviewed
resulting in removal of redundant sections and inclusion of ‘best
practice’ format.
Amended to incorporate Lancashire’s Electronic Care System and
Patient Transport Service Patient Report Form. Amended name
changes within the Trust. Updated Section 7 Monitoring Compliance
Amended to include 111 Clinical Records, updated acronyms, added
the data.protection email address into section 5.3.
Added “A PRF must be completed every time a clinician arrives at an
incident, even if there is no patient as all information needs to be
capture when the forms are scanned. It is vital the incident number is
written legibly and is the correct number of digits” Page 19
4.1
Nov
2014
12 Jan
2015
Y Cutler
Amended and updated the Responsible Director from Director of
IM&T to Director of Quality. Also, removal of Assistant Director of
Health Informatics and replaced with Head of Informatics
Policy and procedures on clinical records management
Page:
Page 3 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Foreword
The objectives of this policy are as follows:

To ensure that all staff are aware of and understand, the standards that NWAS expects and
requires in relation to Clinical Records and to clarify the Trust’s position with regard to this
environment

To ensure consistent working practices throughout the Trust

This policy will form part of the working practice of staff in order to avoid information
security threats by promoting awareness and good practice.
The Clinical Records Management Policy and Procedures (both documentation and practice) will
be reviewed annually and updated where necessary to maintain currency and relevance.
Staff wishing to discuss or have any questions about this policy should contact the Trust's Clinical
Record Manager.
Policy and procedures on clinical records management
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Page 4 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
CONTENTS
1.0
INTRODUCTION AND SCOPE ..................................................................................... 6
2.0
OBJECTIVES .............................................................................................................. 7
3.0
DUTIES ..................................................................................................................... 7
4.0
PROCESS FOR CREATING RECORDS ......................................................................... 10
5.0
CLINICAL RECORD MANAGEMENT .......................................................................... 11
5.1 Security - Storage ................................................................................................................... 11
5.2 Security – Record Movement ................................................................................................ 11
5.3 Information Retrieval ............................................................................................................. 12
5.4 Retaining and disposing of clinical records ............................................................................ 12
5.5 Training .................................................................................................................................. 13
6.0
AUDIT .................................................................................................................... 13
7.0 MONITORING COMPLIANCE WITH THIS POLICY ............................................................ 14
APPENDIX A
LEGAL OBLIGATIONS THAT APPLY TO RECORDS .................................... 15
Public Records Act ........................................................................................................................ 15
Public Records Act – Records Management Standard RMS1 ...................................................... 15
The Data Protection Act 1998 ...................................................................................................... 15
Human Rights Act 1998 ................................................................................................................ 16
The Caldicott Review.................................................................................................................... 16
Access to Health Records Act 1990.............................................................................................. 16
Crime and Disorder Act 1998 ....................................................................................................... 17
Audit Commission Report ............................................................................................................ 17
Information for Health ................................................................................................................. 17
APPENDIX B – CURRENT RETENTION GUIDELINES .............................................................. 17
APPENDIX C – THE PROCEDURE FOR THE MANAGEMENT OF CLINICAL RECORDS ................ 18
APPENDIX D EQUALITY IMPACT ASSESSMENT .................................................................... 25
Policy and procedures on clinical records management
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Page 5 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
1.0
Introduction and Scope
Clinical Records Management is the process by which an organisation manages all the aspects of
clinical records whether internally or externally generated and in any format or media type, from
their creation to their eventual disposal.
North West Ambulance Service NHS Trust (hereafter referred to as “NWAS” or “The Trust”)
requires clinical records to:
 Support patient care and continuity of care;
 Assist clinical and other audits;
 Support improvements in clinical effectiveness through research;
 Protect the interests of the Trust and the rights of patients and employees, by
providing evidence of patient care given.
Current legislation has a significant effect on record keeping arrangements in public authorities.
All records created and maintained by an NHS body are Public Records. NHS bodies must ensure
that records management policies and procedures are fully compliant with legislation and
Government policy on the management of information and take into consideration guidance on
best practice, namely:
 Public Records Act;
 Public Records – Records Management Standard RMS1;
 The Data Protection Act 1998;
 Human Rights Act 1998;
 The Caldicott Report,;
 Records Management: NHS Code of Practice April 2006;
 Access to Health Records Act 1990;
 Crime and Disorder Act;
 Audit Commission Report,
 NHS Litigation Authority Standards;
 HSC 1998/168: Information for Health. (see Appendix A)
The Data Protection Act 1998, describes the Clinical Record as “consisting of information about
the physical or mental health or condition of an identifiable individual made by or on behalf of a
health professional in connection with the care of that individual.”
The following list is a guide only and is not exhaustive and refers to records in electronic and
paper format
 Patient Report Form (PRF) includes Patient Transport Service PRF and the
Electronic Care System (ECS) currently in use in Lancashire
 Diagnosis of Death (DoD) and associated ECG strip
 Hospital Thrombolysis Checklist (PHT) or Primary Percutaneous Coronary
Intervention (PPCI),
 Vulnerable Adult and Child Forms
Policy and procedures on clinical records management
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Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017



2.0
Urgent Care Desk (UCD) Clinical Records
Emergency Operational Centre (EOC) Clinical Records
111 Service Clinical Records
Objectives
The main objectives of this policy are to ensure:
Accountability – adequate records are maintained to account fully and transparently for all
actions and decisions, in particular:
 To protect legal and other rights of staff or those affected by those actions;
 To facilitate audit or examination;
 To provide credible and authoritative evidence.
Quality – records are complete and accurate and the information they contain is reliable and
relevant.
Security – records are secure from unauthorised disclosure or processing and that access and
disclosure is properly controlled, and audit trails will track all use and movement.
Accessibility – records and the information within them can be efficiently retrieved by those with
a legitimate right of access, for as long as the records are held.
Retention and Disposal - there are consistent and documented retention and disposal
procedures to include provision for permanent preservation.
Training – that all staff are made aware of their clinical record responsibilities through training
programmes and guidance.
Performance Measurement – that the application of clinical records management procedures are
regularly monitored against agreed indicators and action taken to improve standards as
necessary.
3.0
Duties
Chief Executive
The Chief Executive has overall responsibility for records management in the Trust, including the
quality of those records. He delegates this responsibility to nominated Directors as follows.
Trust Board
Is ultimately responsible for ensuring that the Trust complies with relevant legislation in clinical
records management
Policy and procedures on clinical records management
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Page 7 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Executive Management Team
Are responsible for ensuring that adequate resources are made available to support the
management of clinical records and ensure compliance with relevant legislation and national
guidance.
Executive Directors
The Lead Director accountable for clinical records management is the Director of Quality.
The Lead Director should work closely with the Freedom of Information Lead and the
Data Protection Lead where appropriate (currently these responsibilities are held by the Head of
Corporate Communications and the Head of Informatics respectively). It is the Lead
Directors’ responsibility to ensure adequate measures are in place to satisfy legal requirements
and responsibilities i.e. developing and implementing policies and procedures, ensuring adequate
resource commitment etc. The Lead Director will report any issues in the area of clinical records
to the Executive Management Team and Trust Board.
Caldicott Guardian
Has responsibility for:
 Agreeing and reviewing internal protocols governing the protection and use of
patient-identifiable information by Trust staff;
 Agreeing and reviewing protocols governing the disclosure of patient information
across organisational boundaries;
 Ensuring adherence to Patient Confidentiality policies.
The Information Governance Management Group
Has responsibility for:
 Ensuring this policy is approved according to agreed Trust processes
 Monitoring effectiveness and completion of Trust wide action plans
 Monitoring all aspects of records management which includes clinical records, according
to the Trusts Record Management Policy
 Annually reviewing the Training Programme with regard to clinical record keeping
 Reviewing and monitoring the KPIs
 Ensuring that a PRF is available for all patient contacts.
Clinical Records Manager
Is responsible for the overall development and maintenance of clinical records management
practices throughout the Trust, in particular for drawing up guidance for good clinical records
management practice and promoting compliance with this policy in such a way as to ensure the
easy, appropriate and timely retrieval of clinical records.
Policy and procedures on clinical records management
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Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Health Informatics Function
Are responsible for:
 Ensuring all the systems are in place for the retrieval and reporting of clinical records.
Heads of Service/Operational Managers
Ensure that all their teams are aware of their obligations regarding the management of clinical
records and comply with the stipulated procedures. It is also their responsibility to ensure that:





There is an appropriate member of the operational management team who is the
designated lead for the management of clinical records within each operational group;
The Clinical Records Policy and Procedures are included in local induction
programmes;
All quality control processes and clinical audits are fully supported;
Performance, in relation to clinical records, is managed locally, based on reports and
audits;
All requests for information are passed through the approved channels and not
responded to locally.
Health Professions Council (HPC) Requirements
Each State Registered Paramedic has to comply with the following standard issued by the HPC
surrounding record keeping.
Registrant paramedics must


Be able to keep accurate, legible records and recognise the need to handle these
records and all other clinical information in accordance with applicable legislation,
protocols and guidelines
Understand the need to use only accepted terminology (which includes abbreviations)
in making clinical records.
All staff
Whether clinical or administrative, who create, receive and use clinical records have records
management responsibilities. In particular all staff must ensure that they keep appropriate
records of their work in the Trust and manage those records in keeping with this policy and with
any guidance subsequently produced.
Policy and procedures on clinical records management
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Page 9 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
4.0
Process for creating records
Clinical records are a vital part of the NHS professional standards and best practice should always
be followed. Guidance for completion of a Patient Report Form is available on the intranet elearning site and also on the front cover of the PRF.
Accurate, legible and clear notes taken at the time of treatment are often the key to successful
defence of a clinical negligence case and important in the case of risk management. It is the
responsibility of each individual member of staff to ensure that any records created by them are
of an appropriate standard. Paper records must be written contemporaneously using a black pen
that cannot be erased. They must be completed legibly in accordance with the instructions in the
Trust ‘Guidance Notes on Patient Clinical Record Completion’.
Erasers, liquid paper, or any other obliterating agents may not be used to cancel errors; a single
line should be used to cross out and cancel mistakes or errors, and this should be signed and
dated by the person who has made the error.
Abbreviations should be kept to a minimum to aid understanding.
The clinician completing the clinical record must ensure that the incident date, incident number,
call sign and their identity number is included on the record.
Records both paper and electronic shall be created and maintained in a manner that ensures that
they are clearly identifiable, accessible and retrievable in order to be available when required.
Records shall be credible, authoritative, and adequate for the purpose for which they are
intended.
Records shall be full and accurate to the extent necessary to:
 Provide evidence that an action was carried out;
 Prove that policies, procedures and rules have been followed in arriving at a decision;
 Defend against possible claims or future legal action;
 Pass information to those responsible for onward care to advise them what action
occurred, when it occurred, who was involved and the sequence of events;
 Facilitate action by colleagues, successors and those responsible for ongoing patient
care;
 Enable a proper scrutiny of the conduct of the Trust by anyone authorised;
 Respond to a request for information under the Freedom of Information Act;
 Respond to a request for information under the Data Protection Act.
Policy and procedures on clinical records management
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Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Health care professionals have a responsibility to ensure that an accurate record is completed for
every patient attended, and this responsibility is instilled in them during initial training and
reinforced through ongoing training.
5.0
Clinical Record Management
The storage, distribution and disposal of records will conform to the relevant legislation (e.g. Data
Protection Act 1998, Human Rights Act 1998), guidance (e.g. Caldicott), Local Policies (e.g. the
Trust Confidentiality Policy) and take into account best practice. Detailed procedures for each
area are developed and approved and must be followed by all staff involved.
Contractors and third parties carrying out NHS functions have the same responsibilities as any
permanent member of staff. Their contracts must draw attention to obligations regarding
confidentiality, including those specified by the Data Protection Act 1998.
5.1 Security - Storage
On completion of a clinical record the document becomes a legal record detailing the clinical care
delivered during the Ambulance Service element of the patient journey. It is the responsibility of
all staff to ensure that completed clinical records are secure at all times and stored in such a way
as to be easily retrievable when required.
Storage accommodation for clinical records shall prevent environmental damage to the records
and meet health and safety, and fire regulations (Fire Precautions Act 1971, Fire Precautions
(workplace) Regulations 1997).
Records shall be kept secure from unauthorised access but allow accessibility to the information
for appropriate reasons. (Refer to the procedure for the management of clinical records and
access to health records and subject access requests)
Appropriate physical security measures will be in place to control access to areas where records
are stored or used. Designated areas for the storage of clinical records must be away from areas
frequently accessed or populated by non-NWAS staff.
All members of staff responsible for clinical records storage (i.e. members of the operational
management team), shall ensure that the standards regarding storage, as defined in this policy
are adhered to and maintained.
5.2 Security – Record Movement
The movement and location of records shall be controlled to ensure that a record can be easily
retrieved at any time, that any outstanding issues can be dealt with, and that there is an
Policy and procedures on clinical records management
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Author:
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Version:
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Date of Approval:
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Status:
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Date of Issue:
12.01.2015
Date of Review
January 2017
auditable trail of record transactions. Controls will include formalised station storage procedures,
restricted access to completed records on station, controlled collection of records for scanning
etc.
Confidential records are a particularly high security risk when they are being transported
between sites and both the method of transport and the storage of records during transport
should reflect the requirement to maintain security and confidentiality.
All movements of paper records should be tracked, preferably electronically. Tracking
Information should include reference details of the document i.e.
 the title of the document,
 current date,
 the name of person who has withdrawn the record
 Contact details of the person/department to which the record has been sent.
5.3 Information Retrieval
Under the Data Protection Act 1998, the right of “subject access” allows an individual to gain
access to personal data held about them, subject to certain constraints and conditions. NWAS
will review any requests for information relating to clinical records against the specific
requirements of the Data Protection Act and the Access to Health Records Act 1990 before
processing such a request. The Access to Health Records Act 1990 applies to requests for access
to records of deceased patients by their personal representatives. Personal data may be shared
with other people subject to conforming to the Data Protection Act. Formal requests should be
made in writing to the Legal Department by emailing data.protection@nwas.nhs.uk and a fee
may be payable.
Patient information shall not be passed on to others without the patient’s consent, except as
permitted under Schedule 2 and 3 of the Data Protection Act 1998 or, where applicable, under
the common law where there is an overriding public interest. Further guidance on disclosing
patient information can be gained from NWAS Patient Information Confidentiality Policy.
Anonymous clinical records will be released where appropriate, if the request is deemed to be
reasonable, but where it does not conform to the specific purposes of the Data Protection Act.
5.4 Retaining and disposing of clinical records
The Trust has adopted the retention periods set out in the Records Management: NHS Code of
Practice. (Appendix B)
Policy and procedures on clinical records management
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Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
It is the responsibility of the Trust to satisfy itself that records are destroyed in a way that
safeguards against accidental loss or disclosure of content. See the destruction of confidential
waste policy available on the Trust intranet.
It is vital that confidentiality is safeguarded at every stage in the clinical records process and that
the method used to destroy such records is fully effective and secures their complete illegibility.
Normally this will involve shredding, pulping, or incineration under secure and controlled
conditions. The Trust maintains a third party contract with a document management company,
who destroy all paper clinical records once they have been imaged onto another media for long
term archive. Destruction follows documented procedures and is logged and certificated. The
third party company assure the confidentiality of patient information in accordance with the Data
Protection Act and a confidentiality agreement is in place. Any work undertaken by a third party
will comply with ISO standards.
Where copies of clinical records are not required (i.e. Duplicate copies not required for onward
patient care where patient refuses treatment etc. or copy designated for clinical audit is not
required), destruction should be carried out by NWAS staff. The appropriate procedures (The
procedure for the management of clinical records Appendix C) must be followed to ensure a
suitable method of destruction is used. Advice can be sought from the Clinical Records Manager.
(Also see Destruction of Confidential Waste Policy)
Any records in electronic format must either be placed onto a server or archived to disc and
placed in a secure box marked with contents, department, and review date. And either stored in
a lockable room with access restrictions to staff or transferred to an appropriate and Trust
approved storage company/site. (See Appendix B for Retention period)
5.5 Training
Induction training for all new staff and mandatory training for existing staff that may create or
come into contact with clinical records covers the Clinical Records Policy and Procedures and the
requirement to maintain confidentiality will be emphasised. This will be reinforced with internal
communications and e-learning on the Trust intranet. This will include Operational staff,
administrative and support staff who work with clinical records.
Periodic reviews and audits of practice will confirm adherence to documented requirements and
highlight any deficient areas. Re-fresher training will target areas requiring improvement or
corrective action.
6.0
Audit
A Clinical Performance Indicator (CPI) has been developed to audit the standard of PRF
completion across the Trust. A minimum sample of 30 PRFs will be audited each month from
every station. This will be managed locally by designated clinicians. With regards to the ECS
Policy and procedures on clinical records management
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Author:
Clinical Records Manager
Version:
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Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
system in Lancashire all records are available for audit using the database but only a sample will
be used to ensure consistency.
The Healthcare Governance Department will be responsible for the collection of clinical audit
data and the production of subsequent CPI reports.
In order to provide reassurance of clinical records existing for all patients attended, the
Emergency Operation Centre incident data will be reviewed against completed clinical records
held. Where a missing record is identified an investigation will be initiated.
The appropriate responsible service delivery manager will regularly monitor all the procedures to
ensure compliance.
7.0 Monitoring Compliance with this Policy
What
Duties
Legal obligation
that apply to
records
Process for tracking
records
Process for creating
records
How
Monitored through
appraisals and
identification of
weaknesses are
reviewed until
compliance is
achieved
Frequency
Annual
By whom
Line managers
including Trust
Board level
Evidence
Appraisal form and
training needs
identified to
Education and
Training.
As a result of
concerns raised
following an
investigation of a
complaint or
incident
Serious untoward
incidents reporting
As required
Line managers
including Trust
Board level
Documented on
Datix Risk
Management
System
Monthly
Healthcare
Governance
STEISS reporting
EMT
Information
security breach
reporting
Audit trail
reporting available
on the incident
search facility and
all electronic
systems
Clinical record
availability report
Quarterly
Information
Governance Team
KPI and policy and
procedure review
By exception
Clinical Records
Manager
Audit
Bi-annually
Health Informatics
Service Delivery
Information
Governance
Management
Group
Policy and procedures on clinical records management
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Author:
Clinical Records Manager
Version:
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Date of Approval:
12.01.2015
Status:
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Date of Issue:
12.01.2015
Date of Review
January 2017
Process for
retrieving records
Process for
retention, disposal
and destruction of
records
Clinical
Performance
Indicator
completion of
clinical records
Hit/miss function
on incident search
facility.
Monthly
Clinical Record
availability report
Subject access
request log in
sheet
Quarterly
DoH Retention
Schedule adopted
Annually
Clinical audit team
Local Clinical
Performance
Indicator Reports
Bi-annually
Health Informatics
Information
Governance Team
Clinical Records
Manager
Hit/miss audit &
Subject Access
Request KPI
Information
Governance
Management
reporting,
Organisational
Performance
Group and IM&T
Senior
Management
Retention schedule
amended if
changes made
APPENDIX A LEGAL OBLIGATIONS THAT APPLY TO RECORDS
Public Records Act
The Public Records Act relates to all records produced by NHS and Government Organisations.
The Act discusses a framework for record storage and archive in an agreed Public Records
depository. The Act does not provide procedures to be followed, but merely provides the scope
of what should be considered a public record.
Public Records Act – Records Management Standard RMS1
The Records Management Standard provides detailed guidance on best practice relating to the
storage of public records. The applicability of these guidelines will depend on the records to be
stored. The standard covers storage facilities, access security, environmental issues – humidity
and damp, and fire protection.
The Data Protection Act 1998
The Data Protection Act 1998 defines the rules for processing personal information. It requires
any organisation processing personal information about a living individual to respond to requests
from that person regarding how the information may be used, who it may be shared with and on
what basis. It also gives the individual the right to see that information, subject to certain
conditions, and under some circumstances the right to prevent processing.
Policy and procedures on clinical records management
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Date of Approval:
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Date of Issue:
12.01.2015
Date of Review
January 2017
Human Rights Act 1998
This Act binds public authorities to respect and protect an individual’s human rights. This
includes an individual’s right to privacy and a patient’s right to expect confidentiality of their
information at all times.
The Caldicott Review
In March 1996, guidance on The Protection and Use of Patient Information was published by the
Department of Health. This guidance required that when the use of patient information was
justified, only the minimum necessary information should be used and it should be anonymous
wherever possible. In the light of that requirement the Chief Medical Officer established the
Caldicott Committee to review the transfer of all patient-identifiable information from NHS
organisations to other NHS or non-NHS bodies for purposes other than direct care, clinical
research or where there is a statutory requirement, to ensure that current practice complies with
the Departmental guidance.
The Caldicott committee’s report, published in December 1997, included 18 recommendations,
which related to ensuring best practice in the use of information flows between organisations.
Freedom of Information Act 2000
The act creates a general right of access, on request, to information held by public authorities.
Requests by individuals for access to their own personal information will fall outside the act, and
will continue to be dealt with under the Data Protection Act 1998.
Records Management: NHS Code of Practice
Records Management: NHS Code of Practice was published in March 2006 by the Department of
Health as guide to the required standards of practice in the management of records for those
who work within NHS organisations in England. It is based on legal requirements and
professional best practice.
This guidance document replaces and supersedes HSC 1999/053 For the Record. The new code
of practice provides clear and concise records management guidance in an updated format, but
does not introduce any new concepts. The retention guidelines have been updated and affect
both the length of time organisations are required to retain clinical records and also permanent
preservation issues.
Access to Health Records Act 1990
The Access to Health Records Act 1990 provides rights of access to the health records of
deceased individuals for their personal representatives and others having a claim on the
deceased’s estate. In other circumstances, disclosure of health records relating to the deceased
should satisfy common law duty of confidence requirements. All other requests for access to
information concerning living individuals are provided under the access provisions of the Data
Protection Act 1998.
Policy and procedures on clinical records management
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Date of Issue:
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Date of Review
January 2017
Crime and Disorder Act 1998
This Act allows disclosures of information to the Police, Local Authorities, Probation Service or
Health service where disclosure is necessary or expedient for the purposes of any provision of the
Act.
Audit Commission Report
The 1995 Audit Commission report, ‘Setting the Record Straight – A study of hospital clinical
records’, criticised the poor standard of NHS record keeping and strongly recommended that
corrective action should be taken.
The key issues to be addressed are the:
 Legacy of low priority given to records management and related facilities;
 Lack of awareness of the importance of good record keeping;
 Lack of information sharing between professions and work units;
 Tendency to treat records as personal rather than corporate assets;
 Lack of co-ordination between paper and electronic information strategies;
 Need to maintain confidentiality whilst legitimately freeing information.
Information for Health
Information for Health, an information strategy for the Modern NHS 1998-2005 (HSC 1998/168)
sets out an information strategy for the introduction of Electronic Patient Records (EPR) to
eventually replace paper records, which means that the NHS will require effective Records
Management policies to cover electronic as well as paper records.
APPENDIX B – CURRENT RETENTION GUIDELINES
Records Management: NHS Code of Practice
Ambulance
10 years (applies to ALL Ambulance
records –
Clinical Records)NB Where a patient
patient
is transferred to the care of another
identifiable
NHS organisation all relevant clinical
component
information must be transferred to
(including
the patients’ health record held at
paramedic
that organisation)
records made
on behalf of
the
Ambulance
Service)
Limitation Act
Destroy
under
confidential
conditions
N
Policy and procedures on clinical records management
Page:
Page 17 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
APPENDIX C – THE PROCEDURE FOR THE MANAGEMENT OF CLINICAL RECORDS
Introduction
Purpose
The purpose of this Procedure Note is to provide a robust system for the handling of the paper
PRF used by NWAS Paramedic Emergency Service.
Scope and Definitions
The term ‘Clinical Records’ refers to clinical information that has been created and gathered as a
result of the work of the NWAS Paramedic Emergency Service including Community First
Responders, Patient Transport Service and the ECC.
NWAS have a number of Clinical Records in use
 A paper Patient Report Form (PRF) which is completed for every patient attended and
supplementary records for example: Diagnosis of Death (DoD) Child Protection (CP),
Vulnerable Adult (VA) and Pre-Hospital Thrombolysis checklist (PHT) or Primary
Percutaneous Coronary Intervention (PPCI) will stay as separate forms.
 An electronic care system (ECS) is in use by PES in the Lancashire Area
 Urgent Care Desk clinical records are added into C3.
 A paper Patient Report Form (PRF) is in use by the Patient Transport Service
 C3 and Pro QA are the electronic records in the Emergency Operational Centres (EOC)
 111 Service use electronic and paper clinical records.
The above list is not exhaustive and this Procedure Note applies to all employees of the Trust who
handle clinical records in any format.
Responsibility
It is the responsibility of all Trust employees to ensure that they are conversant with and follow
the guidance contained within this Procedure Note. Managers should bring the procedure to the
attention of all new employees on commencement of their role.
1. NWAS PES Patient Report Form and associated clinical records.
A standardised patient report form has been designed by the Medical Directorate.
This incorporates the Patient Report Form (PRF), Required Not Conveyed (RNC) Capacity to
Consent and Pathways.
Diagnosis of Death (DoD), Child Protection (CP), Vulnerable Adult (VA) and Pre-Hospital
Thrombolysis checklist (PHT) or Primary Percutaneous Coronary Intervention will stay as separate
forms.
Policy and procedures on clinical records management
Page:
Page 18 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
A PRF must be completed every time a clinician arrives at an incident, even if there is no patient
as all information needs to be capture when the forms are scanned. It is vital the incident number
is written legibly and is the correct number of digits.
Completion guidance for the PRF is included on the covers of the PRF booklets and on the
intranet as an eLearning package.
2. Storage
2.1 On Vehicle
2.1.1 To comply with Department of Health Code of Practice and Data Protection, opaque courier
pouches should be on all vehicles, and completed clinical records need to be stored in these
pouches until they can be deposited into the deposit box (see below)
2.1.2 All completed forms remain in the pouch until the crew return to station, when they should
be emptied and go into the on-station storage box. Best practice is for the pouch to be emptied
on every return to station to reduce the number of forms held at any one time and therefore
reduce the risk of confidentiality breaches or forms going missing.
2.1.3 The pouch should be stored in lockable cupboard on the vehicle, where this is not possible it
should be stored in the cab.
2.1.4 Vehicles must be locked at all times when unattended, with any completed PRFs stored out
of direct vision.
2.2 On Station
2.2.1 The sector manager will assign a member of their management team the responsibility for
clinical records, that person must ensure that the standards regarding storage of records, defined
in this document, are adhered to and maintained.
2.2.2 Upon each return to station all completed clinical records held must be transferred from the
courier pouch to the clinical records deposit box on station. To allow maximum storage the PRF
should only be folded once making an A4 size before being deposited. Where it is found that a
weeks worth of clinical records will not fit into the box a second box can be obtained from the
Clinical Records Manager.
Policy and procedures on clinical records management
Page:
Page 19 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
2.2.3 On completion of a shift it is the responsibility of the ambulance crew, finishing duty, to
ensure that all completed clinical records are removed from the vehicle and placed in the deposit
box.
2.2.4 The designated area for the storage of all clinical records at station level should fulfill the
following criteria:
 The deposit box must be fixed to a table using the holes in the bottom of the box Service
Delivery will make the necessary arrangements in each Area.
 Station security must be maintained at all times to ensure that the storage of clinical
records remains safe and secure
 Designated areas for the storage of clinical records must be away from areas frequently
accessed or populated by non-NWAS staff
 Clinical records must not be stored on the floor due to risk of flood damage;
 Clinical record storage areas must not be in basements, attics or other areas which may
pose a risk of environmental damage due to humidity, damp etc.
 Completed originals of clinical records must be deposited as soon as possible in a secure
metal storage box which does not allow unauthorised retrieval of documents once
deposited
 Clinical record storage areas must be easily accessible to required staff and not pose any
health & safety risk.
3. Process
3.1 All top copies (white) of the PRF will be deposited in the deposit box on station. Keys will be
held by the Clinical Records Manager, appropriate operational managers and couriers. For
emergency access, this should be a very rare occurrence; NWAS Patient Information
Confidentiality Policy must be adhered to (available on intranet)
3.2 The green (middle) copy that contains patient identifiable information that has not been
passed on to a healthcare professional providing continued care (i.e. A&E, GP etc.) because it was
not appropriate, should be left with the patient for an RNC/Refusal. If it is not appropriate to
leave with a patient this copy should be shredded on station by the member of staff that created
the record.
3.3 Clinical audit copies (yellow) which are not patient identifiable and therefore do not pose any
risk to confidentiality requirements should be filed according to existing clinical audit processes.
3.4 Copies not required for a specific audit must be collected on station and held for 6 weeks
before being shredded. Audit copies not required for clinical audit are kept on station in a box file
or ring binder for reference and disposed of by shredding after 6 weeks. It is recommended that
shredding take place every week for the appropriate batch to reduce the time it should take to
shred a batch.
Policy and procedures on clinical records management
Page:
Page 20 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
3.5 DoD & ECG strip, and PHT/PPCI forms are part of NWAS’ record of care and as such should be
managed in the same way and available for retrieval if required. All of these forms, where used,
should also be deposited in the records deposit box and sent for scanning.
3.6 ECG strips should be stapled to DoD or PHT/PPCI forms and should have the incident number
clearly written. Other ECG strips do not need to be kept and should be shredded.
3.7 Child Protection, Vulnerable Adult and PTS PRF these should continue to follow existing
procedures and processes.
3.8 All of the supplementary forms should have the incident number clearly written and be
stapled behind the corresponding PRF before being deposited. Any audit copies should be filed in
the clinical audit files.
4. Document Transportation
The courier service should have access to all stations and access to the clinical records deposit
boxes. The courier will collect from stations and deliver to a document management company for
scanning.
The courier should access each station and open the deposit box. Collected forms will be placed
in individual mail pouches, the pouch will then be delivered direct to a document management
company. The courier should sign the log/occurrence book to evidence they have visited each
station.
Cumbria Area
The local courier will collect the PRFs from stations and deliver to Salkeld Hall. Transport Logistics
courier will collect from Salkeld Hall on a fortnightly basis and deliver to the document
management company for scanning.
Greater Manchester, Cheshire and Merseyside Areas
The courier will collect weekly from all stations and deliver to the document management
company.
Lancashire Area
As Lancashire has an ePR system, an electronic PRF needs to be completed for every patient. Each
PRF is uploaded and stored electronically. A paper PRF should only be used as a fall back if the
receiving unit does not have a web viewer or if a fault has been reported with the electronic
system. The forms that need collecting from Lancashire will be collected on a monthly basis.
5. Process for retrieving records
In order to comply with the Data Protection Act 1998, Chapter 29, Section 4, Principle 7:
“Appropriate technical and organisational measures shall be taken against unauthorised or
Policy and procedures on clinical records management
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Page 21 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
unlawful processing of personal data and against accidental loss or destruction of, or damage to,
personal data”, Crews will not generally have access to the forms once deposited.
Operational staff are not permitted to remove any clinical records from the box once deposited.
Staff should direct any requests for prfs through their management team.
The clinical records will be scanned by a document management company and the image will be
captured and indexed by incident number and date.
The images are downloaded onto a server. An interface through the intranet incident screen
allows an incident search to also provide the facility to retrieve the corresponding clinical records
image (This will be a PRF, but also DoD/Capacity to Consent etc where applicable). As this is done
through the intranet, permissions are configured to restrict access to authorised staff. Individuals
accessing patient data will be requested to justify the reason for the request before the
information is displayed
5.1 Third Party Requests
All requests for copies of patient report forms made by police and other official bodies must be
validated against data protection requirements before any information is released. (See Access to
Health Records and Subject Access Request Policy and the Patient Information Confidentiality
Policy on the intranet)
5.2 Emergency Operation Centre Requests
Should information be required by the Emergency Operation Centre for jobs completed in the
previous week then the audit copy should be available. Should this not be the case then
authorisation will be given by the appropriate Operational Manager to locate the NWAS copy
from the clinical records box in order to provide the required information. The appropriate
Operational Manager will then be responsible for ensuring that the form is returned to the box as
soon as possible.
5.3 Crew Requests
Police
Should copies of PRFs be requested by crews for reference where the Police are requesting an
interview or statement, then the audit copy should be available and should be used. In cases
where patient identity is required (where multiple patients have been attended) the Operational
Management Team should be contacted and requested to provide access to the deposit box. The
Operational Management Team will then be responsible for ensuring that the form is returned to
the deposit box as soon as possible. Under no circumstances should patient records be viewed by
other NWAS staff or by third parties (i.e.: the Police), unless appropriate authorisation is granted.
This should be a written request for information under section 29 of the Data Protection Act.
(NWAS Patient Information Confidentiality Policy available on the NWAS intranet)
Policy and procedures on clinical records management
Page:
Page 22 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Continual Professional Development
Audit copies contain no patient identifiable information and do not present a confidentiality risk.
Should crews require copies of PRFs for personal development programmes they should obtain a
photocopy of an audit copy. Should the audit copy not be of adequate quality for photocopying
and where it is not required for clinical audit the appropriate supervisor may authorise the use of
the audit copy itself. Under no circumstances should the top or middle copies be given to crews
or photocopied.
5.4 Other requests
Should access to clinical records be required by an employee from NWAS (who does not have
access to the incident search facility) then a written request must be sent to the Clinical Records
and Electronic Care System Manager (contact details are at the end of this document) stating the
records required and the reason for access. These requests should be evaluated and where
appropriate access to specific PRFs will be granted.
6 Process for tracking records
6.1 Missing Records
To ensure that NWAS can track the clinical record process the Health Informatics department will
issue a regular “Clinical Records Availability Report” This report will show that for every patient
where an ambulance has arrived scene there should be a PRF image.
Service Delivery, will ensure, where at all possible, that missing prfs are located or an A&E copy
retrieved where applicable and where feasible, put back into the forms collection process.
Where missing forms are not located after initial searches, the appropriate service delivery
managers will be notified of the details of missing forms, including incident number, date, crew,
summary of incident. The Advanced Paramedic will then discuss this issue with the crew involved
and an incident report will be raised. The managers will monitor incidents of missing prfs
involving ambulance crews and escalate any ongoing issues.
7 Retention & destruction
7.1 Top Copies
All original documents should be put into the clinical record deposit box which will be collected
and delivered by the courier to the document management company for imaging and they will
destroy them on their site once approval to do so has been confirmed by the Health Informatics
department and the Clinical Records Manager.
Policy and procedures on clinical records management
Page:
Page 23 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
7.2 Audit Copies
All audit copies not required for clinical audit will be kept on station for a minimum of 6 weeks
and will then be shredded on station. As these copies are not patient identifiable, there is no
requirement to document their destruction.
7.3 Surplus Carbon Copies
Carbon copies that have not be passed on to the healthcare professional providing continued
care (i.e. A&E, GP etc.), as this was not appropriate, will then be shredded on station by an
appropriate member of the operational management team and a record kept of the clinical
records destroyed.
7.4 Responsibilities for Clinical Records
‘All individuals who work for a 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.
Creating and maintaining clinical records is vital to patient care if records are inaccurate then
future decisions regarding care could be detrimental to the patient. If information recorded is
inconsistent, then records are harder to interpret, resulting in delays and possible errors. The
information entered onto clinical records may be needed for the immediate treatment of the
patient, but also for future research that could lead to improvements in patient care. For NWAS
the Patient Report Form and associated forms make up the clinical record used by NWAS to
document treatment given and this should be fully completed for every incident where we arrive
at scene even if there is no patient. A PRF does not have to be completed when cancelled enroute to a call. The only exception to this is when an RRV arrives on scene together with an
ambulance, as only one record is required for each incident/patient. Any information from the
RRV clinician should be incorporated into the ambulance PRF. In the event of an RRV only
response the RRV clinician must complete a PRF if they have arrived at scene.
Please note that it is the responsibility for a Paramedic or EMT2 to countersign any PRFs which
have been completed by the EMT1, as they are the responsible clinician.
Policy and procedures on clinical records management
Page:
Page 24 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
APPENDIX D
EQUALITY IMPACT ASSESSMENT
Name of Policy, Service or Function
Clinical Records Policy and Procedure.
Equality Impact Assessment carried out by
Chris Gresty, Head of Informatics
Date of Equality Impact Assessment
May 2012
Step 1: Description and Aims of Policy, Service or Function
Overall aims
The aims of this policy and associated procedures
• Establish a framework for Clinical Record Management;
• Define responsibilities for Clinical Record Management;
• Clarify applicable legal requirements.
Who does the policy, service or function affect?
All Trust staff, whether clinical or administrative, who create, receive and use clinical records
How do you intend to implement the policy or service change (if applicable)?

Induction training for all new staff that may create or come into contact with clinical
records shall cover the Clinical Records Policy and Procedures.

Clinical Records is part of the Mandatory Training Programme

This will be reinforced with internal publications. This will include Ambulance staff,
administrative and support staff who work with clinical records i.e.: Community First
Responders, IM&T, Health Informatics, Claims & Complaints, PTS, Clinical Governance,
PALS etc.

Periodic reviews and audits of practice will confirm adherence to documented
requirements and highlight any deficient areas. Re-fresher training will target areas
requiring improvement or corrective action.
Policy and procedures on clinical records management
Page:
Page 25 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Step 2: Data Gathering
Summary of data available and considered

Key data assessed and reviewed: The document complies with mandatory legal
requirements, best practice for handling of patient information and clinical records
management. The document has been written in line with the NHSLA requirements.
Exemplar documents have been gathered and utilised from other NHS Trusts in the
creation of this document set.
Outcomes of data analysis
Equality Group
Evidence of Impact
Gender
No impact, affects all genders equally
Race/Ethnicity
Potential for language barriers.
Disability
No impact, (not a patient carrying vehicle)
Sexual Orientation
No impact, affects all sexual orientation groups equally
Religion or belief
No impact, affects all religions and beliefs equally
Age
No impact, (not a patient carrying vehicle)
General (Human Rights)
No impact on areas covered by the Human Rights Act
Step 3: Consultation
Summary of consultation methods

The policy and procedures document has been presented to stakeholders, service delivery
teams, clinical governance and the project team for input. Service delivery had input and
the document was amended accordingly to reflect this.
Policy and procedures on clinical records management
Page:
Page 26 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Outcomes of consultation
Equality Group
Evidence of Impact
Gender
No impact, affects all genders equally
Race/Ethnicity
No impact, affects all race/ethnicity equally
Disability
No impact, (not a patient carrying vehicle)
Sexual Orientation
No impact, affects all sexual orientation groups equally
Religion or belief
No impact, affects all religions and beliefs equally
Age
No impact, (not a patient carrying vehicle)
General (Human Rights)
No impact on areas covered by the Human Rights Act
Steps 4 & 5: Impact Grid
Relevant Equality Area
Areas of impact identified
Is the impact
positive or
negative?
Key issues for
action
No impact, affects all genders
equally
Gender
Race/Ethnicity
Potential for language barriers.
Disability
No impact, (not a patient
carrying vehicle)
Sexual Orientation
Religion or belief
Age
General (Human Rights)
Negative
The policy and
procedure is
available in all
languages on
request.
No impact, affects all sexual
orientation groups equally
No impact, as the procedure
affects all religions and beliefs
equally
No impact, (not a patient
carrying vehicle)
No impact on areas covered by
the Human Rights Act
Policy and procedures on clinical records management
Page:
Page 27 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017
Step 6: Action Plan
Issue identified and
Action
equalities group or
communities
affected
Potential for language Translation
barriers for staff
services to
be accessed
When
Who
Expected
Outcome
As
required
Clinical
Records
Manager
Resolved issue
Progress
Summary of decisions and recommendations
Access translation service as required and monitor frequency of translation requirements in order
to establish if further action is required to take place.
Step 7: Monitoring arrangements

Periodic reviews and audits of practice will confirm adherence to documented
requirements and highlight any deficient areas. Re-fresher training will target areas
requiring improvement or corrective action
Step 8: Date of next Equality Impact Assessment
This equality impact assessment will be reviewed and a subsequent assessment carried out at the
first of the following occasions:

On review date of the policy and procedure which is detailed as January 2014.
Policy and procedures on clinical records management
Page:
Page 28 of 28
Author:
Clinical Records Manager
Version:
4.1
Date of Approval:
12.01.2015
Status:
Final
Date of Issue:
12.01.2015
Date of Review
January 2017