Clinical Records Management Policy Incorporating Clinical Record Keeping Standards

Transcription

1 Clinical Records Management Policy Incorporating Clinical Record Keeping Standards Clinical Records Management Policy v.4 Information Governance Officer September 2014 Page 1 of 55

2 Policy Title: Executive Summary: Clinical Records Management Policy Incorporating Clinical Record Keeping Standards A definitive policy for the management of clinical records. A framework for improving quality, availability and effective use of records and the monitoring processes to effectively maintain records management standards. This policy also includes national guidance from the Royal College of Nursing and Royal College of Physicians in relation to the expected standards for clinical record keeping in the Trust. Supercedes: Clinical Record Management Policy v 4 Description of Amendment(s): This policy will impact on: Minor amendments to roles and responsibilities and reference to the NHS Code of Practice that has now been replaced by the Records Management Code of Practice for Health and Social Care Clinical practices, administrative practices, employees. Financial Implications: Policy Area: Corporate Document ECT Reference: Version Number: V0.4 Effective Date: November 2016 Issued By: Author: Director of Corporate Affairs & Governance Head of Integrated Governance Review Date: November 2018 Impact Assessment Date: APPROVAL RECORD November 2016 Consultation: Approved by Committees: Approved by Director: Committees / Group Information Governance & Records Group Information Governance & Records Group Director of Corporate Affairs & Governance Date 17/11/ /11/ /11/2016 Integrated Governance Manager November 2016 Page 2 of 55

3 CONTENTS 1 Introduction Scope and definitions Aims of records management systems Roles and Responsibilities Legal and Professional Obligations Retention and Disposal Schedules Process for Management of Clinical Records Clinical Record Keeping Standards Clinical Records Management Audit Training Monitoring Performance Audit Review Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Integrated Governance Manager November 2016 Page 3 of 55

4 1 Introduction 1.1. Records management is the process by which an organisation manages all the aspects of records whether internally or externally generated and in any format or media type, from their creation, all the way through their lifecycle to their eventual disposal The Records Management Code of Practice for Health and Social Care 2016 has been published by the Information Governance Alliance as a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice Trust records are its corporate memory, providing evidence of actions and decisions and representing a vital asset to support daily functions and operations. Records support policy formation and managerial decision making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways Record keeping standards are the minimal requirements for all staff to adhere to in the achievement of effective safe record keeping and documentation of clinical care. The Nursing and Midwifery Council and Royal College of Physicians have set out the minimum requirements for clinical records keeping and these are full endorsed by as the minimal standard for the organisation and all clinical staff. 2 Scope and definitions 2.1 This policy relates to all types of records including: Patient health records (electronic or paper based concerning all specialties); Accident and Emergency records; Theatre registers and minor operations (and other related) registers; X-ray and imaging reports, output and images; Photographs, slides and other images; Microform (microfiche/microfilm); Audio and video tapes, cassettes, CD-ROM; Computerised records; Scanned records; And relates to all health records in use throughout the Trust including for those services based on the hospital site and in the community. 2.2 Records Management is a discipline which utilises an administrative system to direct and control creation, version control, distribution, filing, retention, storage and disposal of records, in a way that is administratively and legally sound, whilst at the same time serving the operational needs of the Trust and preserving an appropriate historical record. The key components of records management are: Record creation; Record keeping; Record maintenance (including tracking of record movements); Access and disclosure; Integrated Governance Manager November 2016 Page 4 of 55

5 Closure and transfer; Appraisal; Archiving; and Disposal. 2.3 The term Records Life Cycle describes the life of a record from its creation/receipt through the period of its active use, then into the period of inactive retention (such as closed files which may still be referred to occasionally) and finally either confidential disposal or archival preservation. 2.4 In this policy, records are defines as recorded information, in any form, created or received and maintained by the Trust in the transaction of its business or conduct of affairs and kept as evidence of such activity. 2.5 Information is a corporate asset. The Trust s clinical records are important sources of administrative, evidential and historical information. They are vital to the Trust to support patient care and treatment and for purposes of accountability. The Trust holds an information asset register. More details relating to information assets can be found in the Information Governance Policy. 2.6 Record keeping is defined 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. 3 Aims of records management systems 3.1 The aims of our Clinical Records Management Systems are to ensure that: records are available and can be accessed records and the information within them can be located and displayed in a way consistent with its initial use and that the current version is identified where multiple versions exist; records can be interpreted the context of the record can be interpreted: who created or added to the record and in which location when, during which process, and how the record relates to other records; records can be trusted the record reliably represents the information that was actually used in, or created by, the clinical process, and its integrity and authenticity can be demonstrated; records can be maintained through time the qualities of availability, accessibility, interpretation and trustworthiness can be maintained for as long as the record is needed, perhaps permanently, despite changes of format; records are secure from unauthorised or inadvertent alteration or erasure, that access and disclosure are properly controlled and audit trails will track all use and changes. To ensure that records are held in a robust format which remain readable for as long as records are required; records are retained and disposed of appropriately using consistent and documented retention and disposal procedures, which include provision for appraisal and the permanent preservation of records with archival value; and staff are trained so that all staff are made aware of their responsibilities for record keeping and record management. Integrated Governance Manager November 2016 Page 5 of 55

6 4 Roles and Responsibilities 4.1 The Chief Executive is the accountable officer and has overall responsibility for ensuring that information governance is applied through the organisation 4.2 The Director of Corporate Affairs and Governance is the Trust s Senior Information Risk Owner (SIRO) and has delegated accountability for:- The Data Protection Act IG Toolkit Records Management Information Security Registration Authority activity 4.3 The Associate Medical Director Clinical Effectiveness will act as the Caldicott Guardian and will take a lead on Confidentiality issues. a. To act as a champion for data confidentiality at Board level. b. To develop a knowledge of confidentiality and data protection matters including links with external sources of advice and guidance. c. To ensure that confidentiality issues are appropriately reflected in organisational strategies, policies and working procedures for staff. d. To oversee all arrangements, protocols and procedures where confidential social care information may be shared with external bodies including disclosures to other public sector agencies and other outside interests 4.4 The Deputy Director of Corporate Affairs and Governance (Deputy SIRO) is responsible for ensuring that systems and processes are implemented to ensure sound information governance across the Trust. This includes management of the information governance team budget. 4.5 The Head of Integrated Governance provides assurance reports to the Information Governance & Records Management Group meeting, manages the information governance team, monitors compliance with the IG Toolkit and oversees the archiving and retention of records. 4.6 The Integrated Governance Manager has overall responsibility for operational management of Information Governance and for the implementation and coordination of the information governance work programme across the Trust including providing guidance for good records management practice and promoting compliance with this policy although responsibility for specific requirements is devolved to specialist leads and service managers. 4.7 Operations Manager - Outpatients is responsible for the maintenance of the patient casenote and has overall responsibility for the management of the health records library function and its procedures and will work with the Associate Medical Director, Clinical Effectiveness / Deputy Caldicott Guardian in this regard. 4.8 Managers and Supervisors will be responsible for ensuring the local implementation of information governance and that they implement this and appropriate information policies within their sphere of responsibility. This includes taking appropriate management action should non-compliance arise. Clear Integrated Governance Manager November 2016 Page 6 of 55

7 accountability arrangements will ensure that staff are held to account for the work that they do and this will be reinforced through contractual arrangements. 4.9 Employees, Volunteers, Contractors, sub-contractors all Trust staff, whether clinical or administrative, employed, sub-contracted or volunteers, have a responsibility to ensure compliance with this and other Information Governance policies and procedures and must undertake annual training via the on line IG Training Toolkit. 5 Legal and Professional Obligations 5.1 All NHS records are public records and the Trust will take necessary actions to comply with the legal and professional obligations set out in the Records Management Code of Practice for Health and Social Care 2016, in particular: The Public Records Act 1958 the Act sets out broad responsibilities for everyone who works with NHS records, defined as public records under the Act; The Data Protection Act 1998 regulates the management of personal information held both manually and on computer; The Freedom of Information Act 2000 provides a general right of access to recorded information held by public authorities; The Common Law Duty of Confidentiality based on precedent and case law, determines that healthcare providers must obtain patient consent to disclose personal information outside of the health care team; NHS Confidentiality Code of Practice offers guidance on protecting confidentiality, informing patients about uses of their personal information and the circumstances in which confidential information may be used or disclosed and any new legislation affecting records management that is subsequently agreed. 6 Retention and Disposal Schedules 6.1 It is a fundamental requirement that all health records are retained for a minimum period of time for legal, operational, research and safety purposes. The length of time will depend on the clinical record type and its importance to business functions. The Trust has adopted the retention periods set out in the Records Management Code of Practice for Health and Social Care 2016: 6.2 Notes are retained within the Health Records Library for 12 months plus current year. Deceased casenotes can be sent to Deepstore after 6 months. All case notes prior to this timeframe are available within the digital image system or available from off site storage at Deepstore. If casenotes are required from Deepstore there is a 24 hour turnaround in place should casenotes be required urgently. 6.3 Record Management & Storage of Child Health/School Health Records following Death. Child Health/School Health record to be marked DECEASED clearly across the front of the file. Community record to be tracked on computer system by whoever is currently in possession and record returned to relevant Clinic/School Health Base. Record to be filed in mainstream filing to follow retention policy as for all child records. 6.4 Records are retained disposed and destroyed of appropriately - using consistent and documented retention and disposal procedures, which include provision for appraisal and the permanent preservation of records with archival value. Detailed guidance on Integrated Governance Manager November 2016 Page 7 of 55

8 retention periods for a full range of NHS personal health and different types of business and corporate records is provided in the Information Lifecycle and Records Management Policy and staff are trained - so that all staff are made aware of their responsibilities for record-keeping and record management. 7 Process for Management of Clinical Records The organisation has approved documentation which describes the process for managing the risks associated with clinical records in all media. 7.1 Accurate recording and knowledge of the whereabouts of all records is crucial if the information they contain is to be located quickly and efficiently. One of the main reasons why records get misplaced or lost is because the next destination is not recorded anywhere 7.2 Tracking mechanisms should record the following (minimum) information The item reference number or other identifier A description of the item (e.g. the file title) The person, unit or department, or place to who it is being sent The date of transfer to them 7.3 Process for tracking the main hospital record There is an electronic process for tracking the main hospital record through the PAS system and all appropriate staff will receive training in using the electronic system. Ongoing support and training is available within the Trust by a dedicated trainer. 7.4 Process for tracking A&E Admissions Where an admission occurs as the result of an A&E attendance, the appropriate proforma is to be completed (either medical or surgical). Where the casenote has arrived at A&E, the pro-forma is to be filed before transfer to the ward. Where the casenote is not available to A&E staff, the pro-forma is to accompany the patient to the ward whereby the admitting Ward staff to be responsible for ensuring that the admissions pro-forma is filed within the notes appropriately. 7.5 Manually operated tracking systems The following methods for manually tracking the movement of active records are suggested (specifically for community health records or those records held within departments): A paper register - a book, diary or index card to record transfers File absence or tracer cards put in place of absent files Record on a computer data base Those teams using such manual tracking process to produce and have available procedure/guidance documentation to detail the local process. 7.6 Process for creating hospital health records The process for the creation of records within the organisation is as followed and is a set standard for the organisation and all staff creating clinical records: Search the MPI (Master Patient Index) for the patient (see Patient Management System (PMS) procedure for Searching MPI) Integrated Governance Manager November 2016 Page 8 of 55

9 If the patient is not already recorded on MPI interrogate the National Strategic Tracing Service (NSTS) database for NHS number Search the MPI by NHS number to ensure the patient is not registered under a different name/address/date of birth If patient not found on MPI, register patient using ORE function. The Basic Details screen must be completed in full PMS will then require a casenote to be allocated. All casenotes should be allocated to Main file. NB: No physical record will be created until requested e.g.: by Emergency Admissions or Outpatients The patient Registered GP details must be completed and any other Registration Details provided To complete the process an episode must be opened (see PMS procedure) To register a patient without an episode use PMI function following the above procedure. Use option 3 casenotes to allocate a casenote. 7.7 Process for creating community-based health record Community services must adhere to the documented process for creating local health records. Copies of the local processes are available from the Service Lead. 7.8 Process for retrieving records To ensure that clinical records are retrieved in an effective timely manner the following process is to be followed: Placement of files/records Case notes are in the Health Records Library Hospital case notes held outside of the Health Records Library Community case notes Case notes stored as digital image In the case of missing/misfiled notes In the case of records stored within the organisation s Archive Facility - Deepstore Method for retrieving Files are removed from the library storage system where they are kept in numerical order according to unique patient ID number To be tracked on PAS to requesting department, with clear instructions to advise of further movement. To be tracked using the locally-approved manual tracking system (as outlined in section 7.4 above) The system and individual files are password protected. Training is given to all appropriate staff to enable effective use of the system. User enters individual password to access system, enter unique patient ID number to bring up patient notes for viewing. Staff should following the procedures laid out in the Management of Patient Casenote Procedure attached as Appendix 4 Staff should follow the procedure laid out in Appendix 8 A Guide to Deepstore Procedures Integrated Governance Manager November 2016 Page 9 of 55

10 8 Clinical Record Keeping Standards 8.1 Good Record keeping is an integral part of the care of all patients and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow. 8.2 Good record keeping, whether at an individual, team or organisational levels has many important functions. These include a range of clinical, administrative and educational uses as well as legal ones. 8.3 The principles of good record keeping apply to all types of records, regardless of how they are held. These can include: Handwritten clinical notes s Letters to and from other health professionals Laboratory reports X-rays Printouts from monitoring equipment Incident reports and statements Photographs 8.4 The basic principles of good record keeping are: Every item 1 will include the patients name, identification number (NHS Number), date of birth, location in hospital and consultant in charge of the care. This information should be specified each time an entry is made in the notes. It is envisaged that staff will be working towards achieving the Royal College of Physician s guidance to be followed in that patient identifying information to be included on every side of every page throughout the record and that the Trust s paperwork will be amended to reflect this aspirational requirement. In addition, record keeping standards state that the following principles should apply to all health records: Handwriting should be legible. All entries to records should be signed. In the case of written records, the person s name and job title should be printed alongside the first entry. The name and designation of the person making the entry should be legibly printed against their signature. All entries will have the date and time recorded in 24 hour clock. This should be in real time and chronological order and be recorded as close to the actual time as possible. If there is a delay the time of the event and the delay should be recorded with the entry commencing with Written in retrospect for... 1 An Item can be: - a standalone sheet whereby the ID should be placed on at least one side - an integrated clerking proforma bundle - charts/results - X-ray reports - s printed off and included in the notes Integrated Governance Manager November 2016 Page 10 of 55

11 Records should be accurate and recorded in such a way that the meaning is clear. Records should be factual and only include approved abbreviations. The list of approved abbreviations is available on the Trust s web-site. Health records should not contain jargon, meaningless phrases or irrelevant speculation. Professional judgement should be used to decide what is relevant and what should be recorded. Record details of any assessments and reviews undertaken and provide clear evidence of the arrangements which have been made for the future and ongoing care of the patient. This should also include details of information given about care and treatment. Records should identify any risks or problems that have arisen and show the action taken to deal with them. All staff have a duty to communicate fully and effectively with their colleagues, ensuring that they have all the information they need about the people in their care. No staff must alter or destroy any records without being authorised to do so. If you need to add something to a medical record or make a minor correction contemporaneously (e.g. correct a spelling error or insert/delete a word or two) then do not obliterate an entry that you wish to correct run a single line through it so it can still be read and continue your sentence as usual. If there is a need to insert using a caret (omission mark ^), for example, a missed word, then do so and adhere to the following procedure. a) Make the minor amendment unambiguously and transparently. b) Put your initials clearly beside the entry in question. c) Ensure that your full name, together with your initials, has been documented in the records so that it is evident who made the amendments. d) The date this took place should be inserted in the shortest form possible, besides your initials; e.g. 22/9/14 for 22 nd September 2014 (even 22/9 if it is clear which year is referred to). The above procedure is to amend minor imperfections during the completion of records. For anything more than minor changes to records the approach outlined below for retrospective amendments should be followed: In the unlikely event that a staff member needs to alter their own or another healthcare professional s records retrospectively 2, they must give their name and job title, and sign and date the original documentation. They should make sure that the alterations they make, and the original record, are clear and auditable. All such deletions and alterations have to be countersigned by the member of staff making them and with a date and time (24hrs clock) entered when this occurred. 2 when an alteration / deletion has been made retrospectively in the case notes this should be stated and the reason for this recorded Integrated Governance Manager November 2016 Page 11 of 55

12 Where appropriate, the patient, or their carer, should be involved in the record keeping process. Every entry in the medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made. On each occasion the consultant responsible for the patient care changes, the name of the new responsible consultant and the date and time of the agreed transfer of care should be recorded. Advance decisions, consent and resuscitation status statements must be clearly recorded in the medical records. Records should be readable when photocopied or scanned. Coded expressions of sarcasm or humorous abbreviations to describe the people in your care should never be used in any circumstances. All records must be written in black ink with the exception of operation / procedure notes. No member of staff should ever falsify records. The patient s complete medical record should be available at all times during their stay in hospital. The contents of the medical record should have a standardised structure and layout. Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order. Data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma. An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four (4) days for acute medical care or seven (7) days for long-stay continuing care, the next entry should explain why. The discharge record/discharge summary should be commenced at the time a patient is admitted to hospital. Advance directives, consent and resuscitation status statements must be clearly recorded in the medical record. (These are to be recorded within the ALERTS section of ECNHST records) 8.5 Good record keeping standards for the safe, effective care of patients are endorsed and supported by: Nursing and Midwifery Council Royal College of Physicians The Chartered Society of Physiotherapy College of Occupational Therapists The Society of Radiographers Integrated Governance Manager November 2016 Page 12 of 55

13 9 Clinical Records Management Audit 9.1 The Trust will regularly audit clinical records management practices for compliance with this framework and establish an audit programme which is that each Service Area will audit an agreed number of case notes, as approved by the Information Governance and Records Management Group on an annual basis. Each Service Area to work with the Clinical Effectiveness Department to produce a work plan to ensure that their audit is representative. Each audit must be registered with Clinical Effectiveness who will support the Service Areas in the audit process. 9.2 The audit reports using the standard Trust audit documentation report will be agreed by the Information Governance & Records Management Group and sent to Associate Directorates for action within each Service Area. Results and progress reports will be monitored by the Directorate SQS meeting and will inform future training requirements and highlight underperforming areas. Once action plans are agreed and completed a follow up audit must take place. If the Trust compliance target is not achieved a re-audit will be carried out each year, using Trust approved pro-forma. 9.3 A combined audit report of all the Service Area casenotes audit will be presented to the Information Governance and Records Management Committee on an annual basis 9.4 Managers will be responsible for regular, localised monitoring of the quality of documentation and that standard good practice guidance is adhered to. 10 Training 10.1 All staff are obliged to undertake the annual IG Training Toolkit update which includes standards of record keeping Line Managers will be responsible for arranging any ongoing training for applicable staff in record keeping, case note handling and general clinical records practice in accordance with their personal development plan and departmental role requirements New staff will receive training through corporate and local induction All training provided to staff will be in line with the Data Protection Act 1998 and the Caldicott Report Monitoring Performance 11.1 The trust will audit its records management practices which includes the audit requirements for Service Areas as outlined in section The audit will Follow a mechanism of adapting the policy to cover missing areas if these are critical to the creation and use of records Set and maintain standards by implementing new procedures, including obtaining feedback where the procedures do not match the desired levels of performance Integrated Governance Manager November 2016 Page 13 of 55

14 Highlight where non-conformance to the procedures is occurring and suggest a tightening of control and adjustments to related procedures 11.3 All incidents relating to records management and or clinical record keeping will be reported via the Trust incident reporting system and reviewed in line with the Trust processes. 12 Audit 12.1 This policy will be audited in line with the KPI s identified in section 9 and 11 as a minimum on an annual basis and reported to the Information Governance and Records Management Group. Any action plans developed from this audit will be agreed by the Group with a quarterly review of progress All audits should be registered with the Trust Department for Clinical Effectiveness. 13 Review 13.1 This policy will be reviewed by the Information Governance & Records Management Group as a minimum every 2 years or sooner if new legislation, codes of practice or national standards is introduced. Integrated Governance Manager November 2016 Page 14 of 55

15 Appendix 1 In-Patient Clinical Records Management Audit Pro-Forma Auditor: Date of audit: Ward/Specialty: Job Title & Contact: Patient NHS Number: Consultant: The last episode of care from admission to discharge should be audited. Section 7 Prescription record may be completed by Pharmacy staff by prearrangement. Service Line Specialty 1. Durability/Condition of File a) Unified record/folder format (Trust Structured Folder) b) Case note volume recorded (where more than one volume, alert sticker should be on the front of file and information recorded inside front cover of case notes (e.g. microfilmed/microfisched or stored). c) Folder in good condition d) Are all the contents securely fastened 2. BASIC STANDARD Identification Data Records should contain this information on every item 3 (including charts etc.) a) Patient s name b) Date of birth c) Location of patient (in hospital) d) NHS Number (if NHS number not recorded is the hospital number recorded) e) Consultant in charge (on patient ID sheet) f) GP Details (on patient ID sheet) Yes Yes No No 3.1 Dates, signatures, legibility Yes No a) All entries contain the Doctor/Nurse/Therapist s name legibly printed b) All entries to records are signed c) All entries contain the grade of staff d) All entries have been dated e) All entries have been timed f) All entries have been timed using 24 hour clock g) All entries are legible (easily read and understood by all) 3 An Item can be: - a standalone sheet whereby the ID should be placed on at least one side - an integrated clerking proforma bundle - charts/results - X-ray reports - s printed off and included in the notes Integrated Governance Manager November 2016 Page 15 of 55

16 3.1 Dates, signatures, legibility Yes No h) All entries are written in black ink (with the exception of operative notes) i) Do entries comply with Trust abbreviations 3.2 Alterations Inserted/Deleted that have been made Contemporaneously (at the time) a) Have alterations inserted/deleted been scored through using one line so that the original record is still legible. b) Have alterations inserted/deleted been initialled/signed c) Has a name and initials been given on the record to identify who made the alterations inserted/deleted d) Have alterations inserted/deleted been dated Yes No No Errors 3.3 Alterations/Deletions that have been made retrospectively 2 Yes No No Errors a) Have alterations/deletions been scored out so that the original record is still readable. b) Have alterations/deletions been signed c) Has a name and job title been given on alterations/deletions d) Have alterations/deletions been timed in 24 hour clock format e) Have alterations/deletions been dated f) Have alterations/deletions been countersigned where a staff member has altered their own or another healthcare professional s records retrospectively g) Has a statement been recorded to state why the alteration/deletion was made 2 When an alteration/deletion has been made retrospectively in the case notes this should be stated and the reason for this recorded. 4. Alert Notification Yes No N/A a) Is a Patient Alert Record filed in the casenotes - IF NO go to 4c b) Does the Patient Alert Record contain the patient details c) Is an allergy/intolerance recorded in the casenotes (e.g. on prescription record) d) If yes, is this information recorded on the Patient Alert Record e) ALERT sticker/notification is on the front of the file (if appropriate) *COMPLETE INCIDENT FORM IF ALLERGY/ALERT RECORDED IN FILE, BUT NO ALERT STICKER ON FRONT OF FILE f) If alert sticker on front of file, is there an entry on alert record (inside file) g) Advanced directives statements are recorded on the Alert Record (if appropriate) h) Consent status statements are recorded on the Alert Record if identified by an Advanced directive i) During the last episode of care is there a Do not attempt cardio-pulmonary resuscitation decision documented in the case notes j) If yes, is there a red Do not attempt Cardio-pulmonary resuscitation (DNACPR) form filed at the front of the case notes Integrated Governance Manager November 2016 Page 16 of 55

17 5. Chronologic order Yes No N/A a) Clinical (including midwifery) records written in chronological order b) Is the record contemporaneous? (Notes made at the time or shortly after the event) c) Date for admission (where applicable) is clearly recorded d) Date for discharge (where applicable) is clearly recorded e) Discharge summary was started on admission (where applicable) f) Are the case note contents filed in the relevant sections 6. Relevant Clinical Information Yes No N/A a) During this admission was it recorded that there was a change of consultant responsible for the patient s care (where applicable) - IF NO go to 6e b) Is the name of the new consultant given in all cases (where applicable) c) Is the date recorded for all these changes d) Is the time recorded for all these changes (using 24 hour clock) e) Do all entries indicate the most senior clinician present (where applicable) f) For in-patient episodes of care, where there is a gap of more than 4 days (acute) or 7 days (long stay) has an explanation been given in all cases g) Where there are statements in relation to Advanced Decisions, has the decision-maker been clearly identified h) Where there are statements in relation to consent has the decision-maker been clearly identified i) Has the capacity of the patient to make consent been recorded j) For in-patient episodes of care, have operation notes been filed in the case notes (if appropriate) k) For in-patient episodes of care, have anaesthetic notes been filed in the case notes (if appropriate) l) Is there evidence that letters from consultants have been copied in to patient m) Discharge arrangements/letter filed appropriately n) A&E records for patients subsequently admitted (if appropriate) o) Records provide clear evidence for future and on-going care 7. Prescription Record (if applicable, for in-patient care) Yes No N/A a) Is a relevant prescription record present? IF NO leave this section blank. If YES, this section may be completed by pharmacy staff call ext 1267 b) Patient name is documented on the record c) Hospital number is documented d) Ward documented e) Consultant documented f) Allergy status documented g) Drug name printed clearly h) Drug name written generically or using brand name where appropriate i) Dose expressed in appropriate units with no inappropriate abbreviations Integrated Governance Manager November 2016 Page 17 of 55

18 j) Route documented and legible k) Signed by prescriber l) Surname legibly printed m) Date treatment to commence (including year) n) Numbers used (NOT Roman numerals) o) English instructions are used p) Times of administration annotated q) With stop or review dates for anti-infectives r) Maximum dose documented where applicable s) Line through discontinued item t) Discontinuation signed u) Discontinuation dated v) If prescription chart is full/messy, has a new prescription chart been written? w) If more than one prescription chart in use is this clearly indicated at the top of each chart i.e. 1 of 1, 1 of 2 Additional Comments Thank you for your time completing this form Please send the completed proformas to: Clinical Effectiveness Team Top Floor, New Alderley House Macclesfield Hospital Integrated Governance Manager November 2016 Page 18 of 55

19 Appendix 2 Outpatient/Therapies Clinical Records Management Pro-forma Auditor: Date of audit: Service: Job Title & Contact: Patient NHS Number: Consultant: Audit the last episode of care 1. Durability/Condition of File a) Unified record/folder format (Trust Structured Folder) b) Case note volume recorded (where more than one volume, alert sticker should be on the front of file and information recorded inside front cover of case notes (e.g. microfilmed / microfisched or stored). c) Folder in good condition d) Are all the contents securely fastened 2. BASIC STANDARD Identification Data Records should contain this information on every item 4 (including charts etc.) a) Patient s name b) Date of birth c) Location of patient (i.e clinic) d) NHS Number (if NHS number not recorded is the hospital number recorded) e) Consultant or Healthcare professional in charge (on patient ID sheet) f) GP details (on patient ID sheet) Yes Yes No No 3.1 Dates, signatures, legibility, accuracy Yes No a) All entries contain the Doctor/Nurse/Therapist s name legibly printed b) All entries to records are signed c) All entries contain the grade of staff d) All entries have been dated e) All entries have been timed f) All entries have been timed using 24 hour clock g) All entries are legible (easily read and understood by all) h) All entries are written in black ink (with the exception of operative/procedure notes) 3.2 Alterations Inserted/Deleted that have been made Contemporaneously (at the time) Yes No No Errors 4 An Item can be: - a standalone sheet whereby the ID should be placed on at least one side - an integrated clerking proforma bundle - charts/results - X-ray reports - s printed off and included in the notes Integrated Governance Manager November 2016 Page 19 of 55

20 a) Have alterations inserted/deleted been scored through using one line so that the original record is still legible. b) Have alterations inserted/deleted been initialled/signed c) Has a name and initials been given on the record to identify who made the alterations inserted/deleted d) Have alterations inserted/deleted been dated 4. Alert Notification Yes No N/A a) Is a Patient Alert Record filed in the case notes IF NO go to Q. 4c b) Does the Patient Alert Record contain the patient details 3.3 Alterations/Deletions that have been made retrospectively 2 a) Have alterations/deletions been scored out so that the original record is still readable. b) Have alterations/deletions been signed Yes No No Errors c) Has a name and job title been given on alterations/deletions d) Have alterations/deletions been timed in 24 hour clock format e) Have alterations/deletions been dated f) Have alterations/deletions been countersigned where a staff member has altered their own or another healthcare professional s records retrospectively c) Is an allergy/intolerance recorded in the case notes (e.g. on prescription record) d) If yes, is this information recorded on the Patient Alert Record e) ALERT sticker/notification is on the front of the file (if appropriate) *COMPLETE INCIDENT FORM IF ALLERGY/ALERT RECORDED IN FILE, BUT NO ALERT STICKER ON FRONT OF FILE f) If alert sticker on front of file, is there an entry on alert record (inside file) g) Advanced directives statements are recorded on the Alert Record (if appropriate) h) Consent status statements are recorded on the Alert Record if identified by an Advanced directive 2 When an alteration/deletion has been made retrospectively in the case notes this should be stated and the reason for this recorded. Integrated Governance Manager November 2016 Page 20 of 55

21 5. Chronologic order Yes No N/A a) Clinical (including midwifery) records written in chronological order b) Is the record contemporaneous? (Notes made at the time or shortly after the event) c) Date for discharge (where applicable) is clearly recorded d) Are the case notes contents filed in the relevant sections 6. Relevant Clinical Information Yes No N/A a) Is the name of the new healthcare professional given in all cases (where applicable) b) Is the date recorded for all these changes c) Is the time recorded for all these changes (using 24 hour clock) d) Where there are statements in relation to Advanced Decisions, has the decision-maker been clearly identified e) Where there are statements in relation to consent has the decision-maker been clearly identified f) Has the capacity of the patient to make consent been recorded g) Discharge arrangements/letter filed appropriately h) Records provide clear evidence for future and on-going care Additional Comments Thank you for your time completing this form Please send the completed proformas to: Clinical Effectiveness Team Top Floor, New Alderley House Macclesfield Hospital Integrated Governance Manager November 2016 Page 21 of 55

22 Appendix 3 Clinical Records Management Audit Pro-forma for those working in the community setting Auditor: Date of Audit: Patient NHS Number: Please audit the last episode of Care Service & Location Patient ID: Clinician ID: 1. Referral Yes No N/A a) Date of referral? b) Source of referral? If N/A please specify: 2. BASIC STANDARD Identification Data Records should contain this information on the front sheet a) Full name? b) Date of Birth? c) Address? d) GP Details? e) NHS Number? Yes No 3. Initial Assessment Yes No N/A a) Has an initial Assessment form been fully completed? b) Where the assessment has identified a clinical risk, has this been clearly documented, or a line scored through the box? c) If applicable, are all allergies recorded, or a line scored through the box? If N/A please specify: 4. Patient Care Yes No N/A a) Has a named healthcare professional/care manager/assessor been identified? b) Has a care/treatment plan been written? c) Do the subsequent sessions reflect the care/treatment plan? d) Has the care plan been reviewed? If N/A please specify: Integrated Governance Manager November 2016 Page 22 of 55

23 5. Consent Yes No N/A a) Where applicable has the Consent form been completed and signed? b) For children under 16, has the parent/guardian given written consent to the treatment plan? If N/A please specify: 6. Discharge from Service Yes No N/A a) Date of discharge? b) Reason for discharge? If N/A please specify: 7. Confidentiality Yes No N/A a) Are all the records stored in a place that ensures confidentiality i.e. a locked cupboard or a locked room? If N/A please specify: 8. Record Management Standards Yes No No Error a) Are all entries written in black ink? b) Are abbreviations used as in the Trust glossary? c) Have all the assessment notes been signed and dated? d) Was the signature legible? e) Were all assessments timed, using the 24 hour clock? f) Was the designation stated? Alterations/Deletions that have been made Contemporaneously/retrospectively 2 g) Have alterations/deletions been scored out so that the original record is still readable. h) Have alterations/deletions been signed i) Has a name and job title been given on alterations/deletions j) Have alterations/deletions been dated k) If the alteration/deletion is retrospective in the case notes, has a reason for the alteration / deletion been stated 2 When an alteration/deletion has been made retrospectively in the case notes this should be stated and the reason for this recorded. Integrated Governance Manager November 2016 Page 23 of 55

24 8. Record Management Standards Yes No No Error l) Have alterations/deletions been countersigned where a staff member has altered their own or another healthcare professional s records retrospectively m) Are all the contents securely fastened? n) Is the record contemporaneous? (Notes made at the time or shortly after the event) o) Is the record legible? p) Is the record in chronological order? q) Are there any gaps between each written session? r) Do the records contain inappropriate judgemental statements/opinions? s) Is the patient s NHS number on every side of every page? t) Is the patient s name on every side of every page? u) Is the patient s date of birth on every side of every page? Additional comments: Thank you for your time completing this form Please send the completed proformas to: Clinical Effectiveness Team Integrated Governance Manager November 2016 Page 24 of 55

25 Appendix 4 Standard Operating Procedure Template Title of Standard Operation Procedure: Storage & Retention of all Medical Casenotes Reference Number: Version No: 3 Issue Date: Review Date: Purpose and Background Scope (i.e. organisational responsibility) Vital functions affected by this procedure: To provide operational guidance on storage of Medical Casenotes that are no longer current either physically (off site), or electronically The Trust has legal responsibility arising from the Data Protection Act 1998 to make sure that its information is available and secure, and that it is not kept for longer than is necessary. All users of medical case notes Monitoring Compliance Requirement to be monitored. Must include all requirements within NHS LA Standards Process to be used for monitoring e.g. audit Responsible individual/ committee for carrying out monitoring Frequency of monitoring Responsible individual/ committee for reviewing the results Responsible individual/ committee for developing action plan Responsible individual / committee for monitoring action plan 1.7 Health Records Management b) legal obligations that apply to records Audit of Deepstore Destruction Schedules Information Governance Manager 4 x annually Health Records Management Sub-Group Information Governance Manager Health Records Management Sub-Group e) how health records are retrieved from storage f) process for retention, disposal and destruction of records g) how the organisation monitors compliance with all of the above. Integrated Governance Manager November 2016 Page 25 of 55

26 Escalations (if you require any further clarification regarding this procedure please contact): Information Governance Officer Consultation: Committees / Group Health Records Management Sub-Group Date Approval Committee Ratified by Committee: Received for information: Information Governance & Records Management Group Information Governance & Records Management Group Trust Internet 1 INTRODUCTION The Trust currently stores approximately 250,000 sets of case notes in paper format. In addition, archived records are stored either physically or electronically, with on-line retrieval functionality which is operational 24/7, (EDM) or Physically within secure storage (Deepstore) 2 GUIDANCE The minimum period of retention of personal health records, no longer required for clinical purposes, should be determined in accordance with the Records Management Code of Practice for Health and Social Care The guidance is applicable to all NHS records and details the recommended minimum retention period for each record type. Full details of the retention schedule are outlined in the Trust Corporate Records Management Strategy (Information Lifecycle Policy) available on the intranet. Further advice can be sought from the Information Governance Officer. THE PUBLIC RECORDS ACT All NHS records, and those of NHS predecessor bodies, are public records under the terms of the Public records Act The Act sets out broad responsibilities for everyone who works with such records, and provides guidance and supervision by the keeper of Public Records. It requires that those records that have been selected for archival preservation are transferred to The National Archives or a Place of deposit appointed under the Act. The maximum period for which records can be kept prior to transfer is usually 30 years (any NHS body that feels it needs to hold records for a longer period must consult with The National Clinical Records Management Policy v.4 Information Governance Officer September 2014 Page 26 of 55

27 Archives). STANDARD PROCEEDURE In line with the guidance and in order to reduce unnecessary storage, the guidelines for retention and destruction of medical casenotes is as follows:- 1. All medical casenotes relating to patients with a current episode of care will be retained on Trust premises. This will include casenotes from all specialties. Where additional records are identified, for example occupational therapy, existence of these records must be cross-referenced to the hospital casenote using the alert system. 2. All medical casenotes relating to one year after discharge will be retained on Trust premises. The Health Records Library will be the only main storage area with all other departments using a loan facility tracked on the PAS system to track records to individual areas. 3. Any medical casenotes relating to patients whose last episode of care is greater than one year will be culled and tracked to Deepstore for storage. 4. All deceased casenotes will be stored one year after date of death and will be made available to the appropriate bodies requiring access e.g. Cancer registry, Clinical Effectiveness. 5. All medical casenotes relating to a Legal case or Complaint must be marked not to be destroyed. The Legal Services department or PALS department are to advise the Health Records Library when the do not destroy mark can be removed and the culling process can be followed. 9. Where there are multiple volume casenotes, volumes other than the current can be stored within the Deepstore facility and tracked on PAS and with Deepstore appropriately. 10. All medical casenotes identified for destruction should be:- Checked by the appropriate Health Records Library staff Comply with legislation Comply with local policies Be kept secure whilst awaiting destruction Be destroyed as confidential waste, with an appropriate destruction certificate obtained. 11. Costs incurred for retrievals will automatically be charged to individual Business Units. Records of retrieval transactions will be maintained by the Health Records Library and re-charged on a monthly basis. APPENDIX 1 - Outlines Records Management Destruction Guidelines in line with the Department of Health reviewed retention schedule. DESTRUCTION OF CONFIDENTIAL PATIENT RECORDS Destruction of confidential medical casenotes must ensure that their confidentiality is fully maintained. Normally destruction should be by incineration or shredding. Where this service is provided by a contractor it is the responsibility of the Trust to satisfy itself that the methods used throughout all stages including transport to the destruction site provide satisfactory safeguards against accidental loss or disclosure. Integrated Governance Manager November 2016 Page 27 of 55