Background
NHS East Midlands records are our corporate memory, providing evidence of actions, decisions and representing a vital asset to support our daily functions and operations. They support Strategy formation and managerial decision-making, protect the interests of NHS East Midlands and the rights of patients, staff and members of the public who have dealings with us. They support consistency, continuity and efficiency and productivity and help us deliver our services in consistent and equitable ways.
Records management, through the proper control of the content, storage and volume of records, reduces vulnerability to legal challenge or financial loss and promotes best value in terms of human and space resources through greater coordination of information and storage systems.
All NHS records are Public Records under the Public Records Act and must be kept in accordance with statutory and NHS guidelines:
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Public Records Acts 1958 and 1967
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Data Protection Act 1998
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Freedom of Information Act 2000
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Connecting for Health Code of Practice on Records Management Parts 1 and 2 2006
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Controls Assurance records management standard, since 1999
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Caldicott Guardian Manual 2006
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Audit Commission, Setting the Record Straight, 1995
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Audit Commission Data December 2002
In addition the Code of Practice on Records and Information Management promulgated by the National Archives under S.46 FOIA is currently being revised – a new edition will be available later in the year and will provide the guidelines for best practice in relation to both manual and electronic records.
Purpose
NHS East Midlands is dependent on its records to operate efficiently and account for its actions. This Strategy is intended to provide robust mechanisms to ensure records are maintained, managed and controlled effectively, commensurate with legal, operational and information needs.
Scope
This Strategy relates to all operational records. Operational records are defined as information, created or received in the course of business, and captured in a readable form in any medium, providing evidence of the functions, activities and transactions.
They include (but are not limited to):
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Administrative records (including personnel, estates, financial and accounting records, contract records, litigation and records associated with complaint-handling)
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Registers that may be kept
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Photographs, slides, and other images
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Microform (i.e. fiche/film)
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Audio and video tapes, cassettes
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Records in all electronic formats
Normally NHS East Midlands does not keep patient health records, Theatre Registers, X-Ray or imaging reports, outputs and images but if these were held for any reason they would be subject to this Strategy.
All records created in the course of the business of NHS East Midlands are corporate records and are public records under the terms of the Public Records Acts 1958 and 1967. This includes email messages and other electronic records.
Objectives
The seven main objectives of this Strategy are:
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Accountability – that 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
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Quality – that records are complete and accurate and the information they contain is reliable and its authenticity can be guaranteed
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Accessibility – that 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 by the organisation
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Security – that records will be secure from unauthorised or inadvertent alteration or erasure, that access and disclosure will be properly controlled and audit trails will track all use and changes. Records will be held in a robust format which remains readable for as long as records are required
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Retention and disposal – that there are consistent and documented retention and disposal procedures to include provision for permanent reservation of archival records
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Training – that all staff are made aware of their record-keeping responsibilities through generic and specific training programmes and guidance
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Performance measurement – that the application of records management procedures are regularly monitored against agreed indicators and action taken to improve standards as necessary.
Implementation
NHS East Midlands will ensure that this Strategy is implemented through by a series of programmes to include:
Records creation
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Development and implementation of procedures for creation of corporate records
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Creation of adequate records to document essential activities
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Structured information (content management, version control) to facilitate shared systems based on functional requirements
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Referencing and classification for effective retrieval of accurate information
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Documented guidelines on creation and use of record systems
Records disposal
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Development and implementation of records management protocol retention schedules and procedures for consistent and timely disposal
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Central storage systems for records requiring long-term retention to include electronic archiving systems
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Mechanisms for regular transfer of records designated for permanent preservation to appropriate archives
Records maintenance
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Assignment of responsibilities to protect records from loss or damage over time
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Access controls to prevent unauthorised access or alteration of records
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Defined security levels for access to electronic records and procedures to amend access authorisations as appropriate when staff move
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Tracking systems to control movement/audit use of records
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Identification and safeguarding key or vital records
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Arrangements for business continuity
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Training and guidance
Training and guidance
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Inclusion of records management functions in job processes where appropriate
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Generic and specific guidance on record-keeping standards and procedures
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Training programmes
Performance measurement
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Development of effective indicators and review systems to improve records management standards and compliance.
Responsibilities
The Chief Executive has overall responsibility for ensuring that records are managed responsibly within NHS East Midlands.
The Information Governance Steering Group is responsible for co-ordinating records management in the organisation and identifying key corporate records and providing guidance and advice on their management and retention. They will also be responsible for identifying an organisational lead for records Management
Directors are responsible for ensuring that the Strategy is implemented in their individual directorates. They will nominate directorate representatives, who will liaise with the Information Governance Workstream Lead on the management of records in that directorate.
Records management responsibilities will be written into all accountable individual’s job descriptions and clear procedures for retention of key records issued. It is the responsibility of all staff to ensure that they keep appropriate records of their work and manage those records in keeping with this Strategy and with any guidance subsequently agreed by the information Governance Steering Group.
