Health Records Management
Foundation
Information Governance (IG) Policy Team
NHS Connecting for Health
Key Learning Points
 What is a health record
 Characteristics of full & accurate health
records
 Why do we keep health records
 Performance measure for health records
 Responsibilities for health records
 Record Lifecycle Management
What is a health record?
A health record includes any
information created by, or on
behalf of, a health professional
in connection with the care of a
patient
What format can a
health record take?
A health record can cover a wide range of material:
 Handwritten medical notes
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Computerised records
Correspondence between health professionals
Laboratory reports
X-ray films and other imaging records
Photographs
Videos and other recordings
Audio recordings
Printouts from monitoring equipment
Characteristics of full & accurate
health records
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Authentic
Reliable
Complete & unaltered
Processes & systems have integrity
Useable
Transferable
Structured
Why do we keep
health records?
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Communication between healthcare professionals
Continuity & evaluation of patient care
Defence of claims & investigation of complaints
GMC Requirement (“Good Medical Practice”)
Risk management
Clinical Governance
Resource utilisation
Research and education
Historical purposes
The health record should be…
Available in the right place at the right time to
support effective patient/doctor contact and to
provide continuity of care
Availability of the complete record when needed
is a key determinant of the performance of
Health Record Services
Responsibilities for Records
‘All individuals who work for an NHS organisation
are responsible for any records which they create
or use in the performance of their duties….. any
record that an individual creates is a public
record.’
Records Management: NHS Code of Practice
There are therefore INDIVIDUAL, STATUTORY &
MANAGERIAL responsibilities for all NHS records,
including health records
Create
Use
Be aware
Close Record
Record Lifecycle Management
Retention
Monitor
Appraisal
Disposal
Control