RECORDS MANAGEMENT POLICY
(Non-Clinical Records)
Version
6
Name of responsible (ratifying) committee
Information Governance Steering Group
Date ratified
12 November 2014
Document Manager (job title)
Information Governance Manager
Date issued
03 February 2015
Review date
30 November 2016
Electronic location
Management Policies
Related Procedural Documents
Records Management Strategy, Records Retention
and Disposal Policy, Health Records Management
Policy
Key Words (to aid with searching)
Records Management, Corporate Records, Retention
and Disposal, Filling
Version Tracking
Version
6
Title of Policy:
Issue Number:
Issue Date:
Review date:
Date Ratified
Brief Summary of Changes
Author
12 November
2014
Update to Training Requirements (section 7) to reflect
Essential Skills Handbook and e-assessment
Update to Monitoring Compliance section (9) to reflect
requirements of the Information Governance
Compliance Framework
Information
Governance
Manager
Records Management Policy (Non-Clinical Records)
6
03 February 2015
30 November 2016 (unless requirements change)
Page 1 of 14
CONTENTS
QUICK REFERENCE GUIDE ............................................................................................................. 3
1. INTRODUCTION.......................................................................................................................... 4
2. PURPOSE ................................................................................................................................... 4
3. SCOPE ........................................................................................................................................ 4
4. DEFINITIONS .............................................................................................................................. 4
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 4
6. PROCESS ................................................................................................................................... 5
6.1. What is a Record? .................................................................................................................... 5
6.2. What is Records Management? ............................................................................................... 5
6.3. Electronic Records Management Requirements ....................................................................... 5
6.4. Effective Electronic Records Management ............................................................................... 6
6.5. Creating a Document or File ..................................................................................................... 6
6.6. Naming Folders, Files and Documents ..................................................................................... 6
6.7. Version Numbers...................................................................................................................... 7
6.8. Structuring Folders and Files .................................................................................................... 7
6.9. Disclosure of Information about Staff ........................................................................................ 7
6.10.
Document Properties ............................................................................................................ 9
6.11.
Creating a Paper Document.................................................................................................. 9
6.12.
Filing Paper Documents...................................................................................................... 10
6.13.
Storage of Paper Records .................................................................................................. 10
6.14.
Electronic Document Imaging ............................................................................................. 10
6.15.
Disposal of Documents ....................................................................................................... 10
6.16.
Destruction of Records ....................................................................................................... 10
6.17.
Retention of Records .......................................................................................................... 10
6.18.
Retention Schedules ........................................................................................................... 11
6.19.
E-mails ............................................................................................................................... 11
6.20.
Confidentiality and Security of Records............................................................................... 11
6.21.
Access to Records .............................................................................................................. 11
6.22.
Sharing Records ................................................................................................................. 11
7. TRAINING REQUIREMENTS .................................................................................................... 12
8. REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 12
9. EQUALITY IMPACT STATEMENT ............................................................................................ 12
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 14
Title of Policy:
Issue Number:
Issue Date:
Review date:
Records Management Policy (Non-Clinical Records)
6
03 February 2015
30 November 2016 (unless requirements change)
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QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. The purpose of this policy is to guide staff towards a systematic, consistent and planned
approach to the management of non-clinical records
2. This policy will outline the specific requirements for management paper and electronic
records, although there will be similarities between these media
3. All staff have responsibility for managing records they create or use, which are public records
and may be disclosed under legal or professional obligations. Records belong to the Trust
and not the individual who created them
4. A record is any recorded information created or received in the course of the Trust’s business
and which needs to be retained in order to provide evidence of business activity, transaction
or decision-making.
5. Records can exist in any media including paper, electronic, photographs and images, and
audio and visual recordings
6. Electronic records must be filed in appropriate locations (not the hard drives of PCs) and
should follow consistent naming conventions to ensure ease of retrieval. Folders should also
be logically structured
7. Paper records should follow similar naming conventions to electronic records and be filed in
suitable environmental conditions
8. Good ‘house keeping’ means records should only be held for the minimum necessary time
(further information can be found in the Records Management: NHS Code of Practice via the
Department of Health website / Information Governance intranet pages)
9. Destruction of records should be undertaken appropriately, e.g. use “Shred-It” bins for
confidential records
10. E-mails can be considered as valuable records and should be managed and filed accordingly
(e.g. use network folders rather than relying on Outlook)
11. Records shared across the Trust should ideally be merged or effectively cross-referenced to
ensure information can be ‘collected once and used many times’
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Records Management Policy (Non-Clinical Records)
6
03 February 2015
30 November 2016 (unless requirements change)
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1. INTRODUCTION
All NHS records are public records under the terms of the Public Records Act 1958. Chief
Executives and senior managers of all NHS organisations are personally accountable for
records management within their organisation. The Secretary of State for Health and all NHS
organisations have a duty under the Public Records Act to make arrangements for the safe
keeping and eventual disposal of all types of their records. In addition, NHS organisations need
robust records management procedures to meet the requirements set out under the Freedom
of Information Act 2000, Standards for Better Health, The Information Governance Toolkit,
CNST record keeping standards, and the National Programme for IT.
Records are a valuable resource because of the information they contain. High quality
information underpins the delivery of high quality, evidence-based health care, and other
service deliverables. Information is of greatest value when it is accurate, up to date and
accessible when it is needed.
Currently, within the Trust, we all have our own personal or directorate methods of managing
records, which, whilst they may be effective at a local level, are not consistent across the Trust.
2. PURPOSE
To provide guidance to all staff within the Trust to ensure there is a systematic and planned
approach to the management of non-clinical records.
3. SCOPE
This policy covers all corporate / administrative records within the Trust. The Health Records
Management Policy covers the management of health and clinical records. Both policies
underpin the Information and Records Management Strategy. This policy will be a dynamic
document, which will evolve as further NHS guidance becomes available, and should be read
in conjunction with the Records Management: NHS Code of Practice (2006) Part 1 and Part 2.
This policy will be divided into 2 sections: the management of electronic records and the
management of paper records, although some areas will overlap.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
C drive is the data storage area in your (specific) PC
P drive is your personal area on the server
G drive is the shared network storage area on the server
5. DUTIES AND RESPONSIBILITIES
The records management function of the Trust should be recognised by the Chief Executive as
a specific corporate responsibility as it provides a managerial focus for records of all types, in
all formats, throughout their lifecycle, from planning and creation through to ultimate disposal.
The Chief Executive should support the clearly defined responsibilities and objectives, and
support adequate resources to achieve this.
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6
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30 November 2016 (unless requirements change)
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The Information Governance Manager has lead responsibility for records management within
the organisation.
Managers with directorate and departmental responsibility for records management must work
with the Information Governance Manager to ensure that there is compliance with this policy.
All staff, whether clinical or administrative, must ensure that they are fully aware of their
responsibilities in respect of record keeping and management. Under the Public Record Act, all
NHS employees have a degree of responsibility for any records that they create or use. Thus,
any records created by an employee of the NHS are public records and may be subject to both
legal and professional obligations.
6. PROCESS
6.1. What is a Record?
A record is any recorded information created or received in the course of Trust business,
which needs to be retained to provide evidence of a business activity, transaction or decision.
Records can exist in any format or media, including paper, electronic, photographs and
images, and audio and visual recordings.
Records capture the information about transactions, decisions and business activity, which
needs to be retained as evidence. Not all documents and files used in a business process will
necessarily need to be captured into record keeping systems. Only those required to provide
an adequate, accurate record of the work carried out or decisions made. The capture of
relevant records into appropriate record keeping systems should be an integrated part of all
Trust business processes.
The content of a record will primarily be determined by the purpose for which it is being
created. Record keeping is a tool of professional practice and one, which should facilitate the
care process. It is not separate from the process and it is not an optional extra to be fitted in.
6.2. What is Records Management?
Records management is the activity of managing records throughout their lifecycle from
creation to disposal or permanent archiving. It includes the capture, maintenance, use,
storage, review and transfer of records.
6.3. Electronic Records Management Requirements
Electronic records within the Trust are to be clearly identified. They must be able to be
preserved and stored for the required period. In order to ensure that the information
constitutes a record the Trust is required and endeavours at all times to ensure that:
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The record is present – the information needed to reconstruct activities and
transactions that have taken place is recorded
The record can be accessed – it is possible to locate and access the information
The record can be interpreted – a context for the information can be established
showing when, where, and who created it
The record can be trusted – the information and its representation exactly matches
that which was actually created and used, and its integrity and authenticity can be
demonstrated beyond reasonable doubt
The record can be maintained – the record can be deemed to be present and can be
accessed, interpreted and trusted for as long as necessary and on transfer to other
approved locations, systems and technologies
Records Management Policy (Non-Clinical Records)
6
03 February 2015
30 November 2016 (unless requirements change)
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6.4. Effective Electronic Records Management
Effective electronic records management supports:
 Efficient joint working and information exchange both internally and with other NHS
organisations
 Evidence-based policy making by providing reliable and authentic information for the
evaluation of past actions and decisions
 Administration of data protection principles and effective implementation of Freedom
of Information and other information policy legislation, through good organisation of
records
6.5. Creating a Document or File
 Each department within the Trust shall keep adequate records to document its
activities. When determining what records are to be kept, managers shall take into
account public accountability, operational, legal and regulatory requirements.
 Records shall be complete and accurate enough to meet accountability, operational,
legal and regulatory requirements.
 As far as possible, there shall be no unwarranted duplication of records.
 Records should be placed within designated record keeping systems that enable them
to be accessed quickly and easily e.g. shared folders.
 Corporate record keeping systems shall classify and group records according to
business function and activity, so that there is sufficient context to relate records to the
business activities that they document.
 Wherever possible, records which have been created or received electronically shall
be captured and stored in electronic record keeping systems i.e. not printed and
stored in paper form.
 Electronic records shall be managed like any other record, in accordance with this
policy.
When creating a new document (or any other file type), the use of templates and document
marking (corporate logo) will help us to create documents with a corporate look. The Trust
logo should always be placed in the top right hand corner of the document and the
recommended font is Arial size 11.
6.6. Naming Folders, Files and Documents
Naming conventions are standard rules to be used for naming both documents and electronic
folders and are used to make it easier to find documents. Corporate standards must be
followed in the naming of record files and folders. It is unacceptable for any documents to
leave the Trust without having either a logical file name or format for presentation that shows
the Trust as being the owner of such documents. This corporate approach to the naming of
electronic files will ensure that current and future staff will be able to create, update and
search for files in a much easier manner than the current system.
Basic file naming practices:
 Give a unique name to each record, which is clear and simple
 Give a meaningful name which closely reflects the records contents
 Use standard terms for organisations, roles, projects, activities and other types of
document (e.g. agenda / report / board paper)
 Express elements of the name in a structured and predictable order
 Locate the most specific information at the beginning of the name and the most general
at the end
 Give a similarly structured and worded names to records which are linked (for example,
an earlier and later version)
Electronic file names should not include excessive wording or inconsistent referencing
formats.
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A file name description (normally the document title). Long words such as,
management, organisation and department, should be shortened to ‘mgt’, ‘org’ and’
dept’. The file name must represent the content of the document. The document status
is appropriate if the document is in preparation e.g. labelled ‘draft’.
A version number in the format of e.g. v1
A date reference may also be used to enable documents with the same titles but
different dates to be distinguished.
The file extension. This is normally allocated by the application i.e. ‘doc’ or ‘xls’. In
general, if you cannot see a file extension, there is no need to add one as it will be
assigned automatically by the application you are using.
All file names must exclude illegal characters. These include \ / *? “ ‘ < > . : Filenames should
also replace a space with an underscore as this allows transfer to other computer systems
keeping the file name in tact.
6.7. Version Numbers
Where the record is likely to be replaced in the future by a new version, e.g. a policy, a
version number should be included, both in the filename and also the document itself (usually
via a template). The format to be used is v1, v2.
The key objective with version numbers is that the most current version is obvious and that
there is an audit trail of previous versions.
6.8. Structuring Folders and Files
A well thought out structure of folders (also known as directories or classification schemes) for
filing documents is a key element to efficient electronic record keeping. There is a balance to
strike between having many levels of folders and having a very ‘flat’ folder structure with
everything under one major heading. Also, if the user needs to trawl through levels of folders
to find the document they are likely to give up.
Folder titles should be clear and concise and adequately describe the contents.
Access to folders can be set up with varying degrees of permissions / controls, depending on
the nature of the contents and who requires access.
The organisation should use a clear and logical filing structure that aids retrieval of records.
Ideally, the filing structure should reflect the way in which paper corporate records are filed to
ensure consistency. However, if it is not possible to do this, the names allocated to files and
folders should allow intuitive filing. Filing of corporate records to local drives on PCs and
laptops is not an acceptable practice.
6.9. Disclosure of Information about Staff
There are generally two main areas where documents can be saved – either shared or
personal folders. Both of which are located on the network.
The use of shared folders should be adopted wherever possible to facilitate the sharing of
Trust information and to improve access to the information during absences of individuals.
Folder structure should allow logical access to data and should typically be set out around
department, activities or projects, rather than the work of individuals. Examples of documents
that should be stored in shared areas include; reports, training materials or staff rotas.
The ICT helpdesk will be able to advise Trust staff on setting up shared folders and providing
mechanisms to control access where required.
Private work-related documents, for example APDR preparation or HR documents, should be
stored in personal folders (P Drive), where they will only be accessible by the relevant
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individual. This area can also be used by staff to store a limited amount of personal items
such as CVs or exam results.
No documents should be stored on the local hard disk drive of your computer (C Drive) as
only information that is stored on the Trust network drives will benefit from the automated
back-up and recovery services and access security controls.
(The data storage area on your computer)
(How your personal drive will look in ‘My Computer’)
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6.10. Document Properties
Describing a document using ‘document properties’ makes searching easier and this will help
to reduce time wasted looking for documents. We need to be able to easily access documents
in order to comply with the Freedom of Information Act as well as maintain business
efficiency.
Staff are required to complete the document properties box on all documents / spreadsheets
that they produce. This task can be made easier by setting the Document Properties box to
appear automatically when first saving a document. All staff should follow the instructions set
out in Appendix 1 for doing this. If you require assistance, please contact the Information
Governance Manager or ICT Helpdesk. By using document properties, it enables the
Microsoft search facility to be used to find Trust documents.
6.11. Creating a Paper Document
Records of business activity should be complete enough to:
 Facilitate an audit or examination of the business by anyone so authorised
 Protect the legal and other rights of the Trust, its clients and any other person affected
by its actions
 Provide authenticity of the records so that the evidence derived from them is shown to
be credible and authoritative
Paper records should be:
 Factual, consistent and accurate
 Written as soon as possible after an event has occurred, providing current information
 Written clearly and in such a way that the text cannot be erased
 Written in such a way that any alterations or additions are dated, timed and signed in
such away that the original entry can still be read clearly
 Accurately dated, timed and signed with the signature printed alongside the first entry
 Not include abbreviations (unless officially approved by the Trust), jargon,
meaningless phrases, irrelevant speculation and offensive subjective statements
 Readable on any photocopies
 Written in black pen, not ink as this can run, and on white paper (other coloured pens
and paper can be used providing the combination of pen and paper produces a legible
and permanent record)
 Not include the use of correction fluid
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6
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6.12. Filing Paper Documents
Where documents are kept as hard copy files, the filing structure and naming of the files
should follow the same principles as described within the management of electronic files. All
records should be arranged in a record-keeping system that will enable the Trust to obtain the
maximum benefit from the quick and easy retrieval of information.
6.13. Storage of Paper Records
In order to comply with statutory requirements, the Trust should be aware of what records it
holds and where they are held. Storage accommodation should be clean and tidy, should
prevent damage to the records and provide a safe working environment for staff. Equipment
used to store records should provide storage which is safe and secure from unauthorised
access, but which allows maximum accessibility to the information in line with its frequency of
use. When records are no longer required for the conduct of current business, they should be
stored appropriately with consideration of NHS retention periods.
6.14. Electronic Document Imaging
Whether for reasons of business efficiency and / or in order to address problems with storage
space, all departments interested in optically imaging records must initially liaise with the
Electronic Document Management (EDM) Manager and not with the Trust’s contractors
independently. This will ensure that appropriate Service Level Agreements are raised and the
work undertaken, meets the Trust’s strategic direction and standards. The ICT Department
needs to be kept fully aware of progress and the future support requirements.
6.15. Disposal of Documents
Disposal of records does not necessarily mean destruction. This could be the transfer of
records from one media to another e.g. paper records to CD Rom, or the transfer of records
from one organisation to another e.g. archivists or commercial storage.
6.16. Destruction of Records
The destruction of records is an irreversible act. Many NHS records contain sensitive and / or
confidential information and their destruction must be conducted in a secure manner to
ensure there are safeguards against accidental loss or disclosure. The normal destruction
method used within the Trust for confidential / sensitive records is shredding. All confidential
waste should be placed in the allocated “Shred-it” consoles or confidential waste bins / sacks.
Non-confidential waste can be placed in the recycle bins. Shredding equipment within
departments must comply with Trust standards. A record of disposal decisions must be kept
for reference.
The secure destruction of computer media is undertaken by the ICT Department. Please
contact them for advice.
If a record due for destruction is known to be the subject of a request for information under the
Freedom of Information Act 2000, destruction should be delayed. It is a criminal offence under
the Act to destroy or alter information that has been requested, in an attempt to avoid
disclosure.
6.17. Retention of Records
As a general rule, information should only be kept as long as absolutely necessary. This
includes deleting:
 Unnecessary duplicates of final documents
 Working copies which are no longer required
 Documents which have no continuing value
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In all cases, ‘good housekeeping’ of paper and electronic filing systems is essential to
maintaining long-term viability, removing material which should no longer be kept, consistent
with this policy. The Trust is only responsible for the retention of its own original documents.
Corporate records that require permanent preservation need to be stored appropriately to
preserve their integrity and availability. If scanning to electronic form is considered, please
refer to 6.5.4.
6.18. Retention Schedules
Currently, NHS guidance for the minimum retention periods for records is set out in the
Records Management: NHS Code of Practice (Part 2), published in April 2006 by the
Department of Health.
If you have any queries relating to the retention of records, please contact the Information
Governance Manager.
6.19. E-mails
It should be noted that emails can be, or be part of, a record of business activity and can fall
within the scope of the Freedom of Information Act, with potential for disclosure into the public
domain. Emails which record business activity must be treated in the same manner as for the
management of electronic records, which means they may be saved to network drives rather
than being managed through Microsoft Outlook.
6.20. Confidentiality and Security of Records
The storage, distribution, use and disposal of records will conform to relevant legislation e.g.
Data Protection Act 1998, Freedom of Information Act 2000 and ISO/IEC 17799 – Information
Security, and NHS guidance such as, Caldicott Principles, NHS Code of Practice on
Confidentiality 2003, and local policies, taking into account best practice. Always consider the
most appropriate method for ensuring confidential information is distributed securely e.g.
password protection.
6.21. Access to Records
Access to medical and personal records is covered by the Data Protection Act 1998 and is
covered by the Trust’s Health Records Management Policy. Access to administrative /
business records is covered by the Freedom of Information Act 2000. Always be mindful that
these records may be disclosed into the public domain, subject to certain exemptions.
6.22. Sharing Records
All staff should work towards rationalising record collections through sharing records and the
information they contain (subject to legal and NHS constraints), by merging or ensuring
effective cross-reference. Information should ideally be collected once and used many times
across departments / organisations. Important points:
 Data belong to the Trust and not to individuals or departments
 Each individual has a responsibility for records they create, but they do not own them
 NHS records are public records and the Chief Executive is ultimately responsible for
all records generated in the Trust
 The Trust recognises that there are restrictions on the disclosure of information and
these are to be respected at all times
 Information sharing protocols can be established for regular information flows
If you are unsure about the sharing of records, please contact your line manager or the
Information Governance Manager.
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Issue Number:
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Review date:
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7. TRAINING REQUIREMENTS
The Information Governance Manager has overall responsibility for maintaining training and
awareness of non-clinical records management for Trust staff, which forms a part of Information
Governance training.
Information Governance training is mandatory and all new starters must receive IG training as
part of their corporate induction.
All staff members are required to undertake accredited Information Governance training as
appropriate to their role. The preferred method is through the Trust’s Essential Skills Handbook
(ESH) and associated e-assessment in the Electronic Staff Records (ESR).
Information Governance training must be completed on an annual basis.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Freedom of Information Act (2000)
http://www.opsi.gov.uk/Acts/acts2000/ukpga_20000036_en_1
Data Protection Act (1998)
http://www.opsi.gov.uk/Acts/Acts1998/ukpga_19980029_en_1
Records Management: NHS Code of Practice DH (2006)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4131747
Connecting for Health – Information Governance Training Tool
http://www.igte-learning.connectingforhealth.nhs.uk/igte/index.cfm
The National Archives’ Records Management: Standards and Guidance
http://www.nationalarchives.gov.uk/recordsmanagement/default.htm
Confidentiality: NHS Code of Practice DH (2003)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4069253
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
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Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement to be monitored
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Corporate records inventories / audits, undertaken as part
of compliance with the Information Governance Toolkit.
These are currently undertaken in line with IGT
requirements, and are based on a minimum number of
departments rather than Trust-wide with routine reviews
The Information Governance Compliance Monitoring Tool,
which audits the availability and awareness of confidential
waste facilities:
o
CSCs should undertake Compliance Monitoring
audits quarterly, in support of their CQC compliance.
Corporate Functions should undertaken compliance
monitoring audits bi-annually.
o
Compliance Monitoring Audits form part of the IG
Compliance Framework, and are therefore reported
into the IGSG bi-annually by all Trust CSCs.
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Lead
Tool
Frequency of
Report of
Compliance
IG Manager
CSC Information
Governance
Steering Group
Representatives
Information Asset
Owners
IG Compliance
Framework
Bi-annual
Reporting
arrangements
Information
Governance Manager
bi-annual Corporate
Information Assurance
reports to the IG
Steering Group
CSC bi-annual reports
to the IG Steering
Group
Lead(s) for acting on
Recommendations
IG Manager
CSC Information
Governance Steering
Group Representatives
Information Asset
Owners
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