NHS TAYSIDE HEALTH RECORDS STRATEGY AND MANAGEMENT POLICY

Transcription

1 Item 8.5 Appendix 1 NHS TAYSIDE HEALTH RECORDS STRATEGY AND MANAGEMENT POLICY Author: Health Records Service Review Group: Information Governance Review Date: April 2012 Last Update: Document No: Issue No: 1 UNCONTROLLED WHEN PRINTED Signed: Executive Lead (Authorised Signatory) docs_ doc Page 1 of 85

2 FOREWORD The Scottish Government has published a revised Records Management: NHS Code of Practice which is intended to be 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 Scotland. The Code also: Provides information on the general legal obligations that apply to NHS records; Recommends best practice to assist in fulfilling these obligations; Explains the requirement to select records for permanent preservation; Addresses the issues raised by medical records incidents, and Sets out recommended minimum periods for retention of NHS personal health records and administrative records. Replaces the following individual circulars:- CEL (2008) 28 Records Management: NHS Code of Practice (Scotland). HDL (2006) 28 The Management, Retention and Disposal of Administrative Records. Seven Guidance Notes have also been published to supplement the updated Code of Practice and provide practical guidance for those working at operational level within the Boards. The code and guidance notes can be viewed at the following links: Code: Guidance Notes: This guidance provided in the Code of Practice is an inherent feature throughout the Policy. docs_ doc Page 2 of 85

3 NHS TAYSIDE - POLICY/STRATEGY APPROVAL CHECKLIST This checklist must be completed and forwarded with policy to the appropriate forum/committee for approval. POLICY AREA: (See Intranet Framework) POLICY TITLE: LEAD OFFICER: Why has this policy/strategy been developed? Has the policy/strategy been developed in accordance with or related to legislation? Please give details of applicable legislation. Has a risk control plan been developed? Who is the owner of the risk? Who has been involved/consulted in the development of the policy/strategy? Has the policy/strategy been assessed for Equality and Diversity in relation to:- Please indicate Yes/No for the following: Health Records Service Health Records Management Brian MacGowan To clarify the required standards of practices in the management of all aspects of health records. Data Protection Act Freedom of Information Act Public Records (Scotland) Bill A specific risk control plan has not been developed. The risk owner will be the Chief Executive & Medical Director. Information Governance Committee, Information Delivery Group, e-health Director, General Managers, Associate Medical Directors, Acting Nursing Director, Associate Nursing Directors, AHP Director, Health Records Staff, Administrative Service Managers,, Employee Director, LNC Chair Has the policy/strategy been assessed For Equality and Diversity not to disadvantage the following groups:- Please indicate Yes/No for the following: Race/Ethnicity Gender Age Religion/Faith Disability Sexual Orientation Does the policy/strategy contain evidence of the Equality & Diversity Impact Assessment Process? Minority Ethnic Communities (includes Gypsy/Travellers, Refugees & Asylum Seekers) Women and Men Religious & Faith Groups Disabled People Children and Young People Lesbian, Gay, Bisexual & Transgender Community This is a Health Records Management Policy which does not impact in any differential way on Equality & Diversity Is there an implementation plan? The implementation plan will be developed with the relevant managers during April. Which officers are responsible for Acute & CHP General Managers. implementation? When will the policy/strategy take effect? July Who must comply with the policy/strategy? All staff who are involved in the management and use of health records. How will they be informed of their Through Implementation Plan and department responsibilities? communication channels. Staff Nett Is any training required? If yes, has any been arranged? Are there any cost implications? If yes, please detail costs and note source of funding. Who is responsible for auditing the implementation of the policy/strategy? What is the audit interval? Yes. The training will be devised during the implementation planning stage. The use of Learn Pro e-training will be part of the training plan No. Overall responsibility for auditing the implementation will lie with Senior Health Records Manager. Local audit will be required within each service area. Monthly but will relate to the detailed Implementation Plan. docs_ doc Page 3 of 85

4 Who will receive the audit reports? When will the policy/strategy be reviewed and by whom? (please give designation) Information Delivery Group. Improvement & Quality Committee. General Managers. Annually, commencing May Name: Date: docs_ doc Page 4 of 85

5 Contents SECTION 1 HEALTH RECORDS STRATEGY & AIMS 1.1 Introduction Vision Scope Aims Key Elements 7 SECTION 2 - HEALTH RECORDS MANAGEMENT POLICY 2.1 Introduction Scope and Definitions Aims of our Records Management System Legal and Professional Obligations Health Records Service Responsibilities Roles and Responsibilities Retention and Disposal Schedules Records Management Systems Audit Training High Level Improvement Plan Standard Operating Procedures Review 14 SECTION 3 RETENTION AND DISPOSAL SCHEDULES 3.1 Introduction Interpretation of Schedule: NHS Tayside Policy for main record types Health Records Retention Schedule of all other record types Resources to support improvement 38 SECTION 4 Appendices APPENDIX 1: Major Service Activities 43 APPENDIX 2: Health Records Service Management Structure 44 APPENDIX 3: Training and Induction 45 APPENDIX 4: Improvement Plan 46 APPENDIX 5: List of current Service Operating Procedures 47 APPENDIX 6 Health Records Inventory Survey 84 Page number docs_ doc Page 5 of 85

6 SECTION 1 HEALTH RECORDS STRATEGY & AIMS 1.1 INTRODUCTION This document sets out an overarching framework for integrating current health records management initiatives, as well as recommending new ones. It defines a strategy for improving the quality, availability and effective use of health records within NHS Tayside and provides a strategic framework for all health records management activities. This will enable overall co-ordination of all health records management activities and ensure alignment with NHS Tayside s business and clinical strategies The Health Records Management Strategy should be read in conjunction with NHS Tayside s Health Records Management Policy and in conjunction with the Records Management: NHS Code of Practice (Scotland) VISION The Health Records Service in Tayside works to support professions in the delivery of health care to patients through the comprehensive management of patients personal health records for clinical, academic, research and other appropriate activities. 1.3 SCOPE 1.4 AIMS A health record is anything that contains information, which has been created or gathered as a result of any aspect of the delivery of patient care. This strategy relates to all health records held in any format by NHS Tayside as detailed in the Scottish Government s publication on Records Management: NHS Code of Practice (Scotland) 2010 and therefore relates to all patient health records for all specialties, including records for private patients treated on NHS premises. Health records will include:- Patient health records for all specialties (electronic, microfilm and paperbased). Radiology and imaging reports, photographs and other images. Computer databases, output and disks, etc., and all other electronic records. Audio and video tapes, cassettes, CD ROM etc. Material intended for short-term or transitory use including notes and spare copies of documents The health record should be constructed to contain sufficient information to identify the patient and provide a clinical history, details of investigations, treatment and medication The aims of NHS Tayside s health records management strategy are to ensure:- A systematic and planned approach to health records management, covering records from creation to disposal. To provide a records and information service of proven quality by constantly monitoring performance and developing services to meet new requirements. Efficiency and best value through improvements in the quality and flow of information and greater co-ordination of health records and storage systems. Compliance with statutory requirements. Awareness of the importance of health records management and the need for responsibility and accountability at all levels. Promote and foster good working relationships within the service and with other services throughout NHS Tayside. To treat patients and staff with courtesy and respect. docs_ doc Page 6 of 85

7 1.5 KEY ELEMENTS The records management strategy comprises the following key elements: Responsibility and Accountability To provide a clear system of accountability and responsibility for record keeping and use of health records (see Section 6 of Health Records Management Policy). It is important that all individuals in NHS Tayside appreciate the need for responsibility and accountability in the creation, amendment, management, storage of and access to all patient health records. A major target is therefore to have a clear chain of managerial responsibility and accountability for all records created by the organisation. This is the pre-requisite for an effectively co-ordinated records management strategy Health Record Quality To create and keep health records which are adequate, consistent and necessary for statutory, legal and business requirements. NHS Tayside health records must be accurate and complete in order to facilitate audit, fulfil NHS Tayside s responsibilities and protect its legal and other rights. Health records will show proof of their validity and authenticity so that any evidence derived from them is clearly credible and authoritative Management To achieve systematic, orderly and consistent creation, retention, appraisal and disposal procedures for records throughout their life cycle. Record keeping systems must be easy to understand, clear and efficient in terms of minimising staff time and optimising the use of space for storage. Policy implementation is the responsibility of the Head of Health Records Service/Senior Health Records Managers/Information Governance Committee (see Section 2.65 of the NHS Tayside Health Records Management Policy) Security To provide systems which maintain appropriate confidentiality, security and integrity for health records in their storage and use. Health records must be kept securely to protect the confidentiality and authenticity of their contents and to provide further evidence of their validity in the event of legal challenge. Overall responsibility for development and maintenance of health records management practices throughout NHS Tayside is the responsibility of the Locality Health Records Managers (see Section of the NHS Tayside Health Records Management Policy) Access To provide clear and efficient access for all employees and others who have a legitimate right of access to NHS Tayside s health records and ensure compliance with Access to Health Records, Data Protection and Freedom of Information legislation. It is the responsibility of Local Clinical Service Managers/Heads of Department/Service to ensure that records controlled within their unit are managed in a way that meets the aims of the NHS Tayside Health Records Management Policy (see Sections and of that document) Audit To audit and measure the implementation of the records management strategy against agreed standards. The performance of the records management programme will be audited to support key elements of creation, use, storage, security and confidentiality as set out in NHS Tayside Health Records Service Operation Procedures (see Appendix 5 to the NHS Tayside Health Records Management Policy). docs_ doc Page 7 of 85

8 1.5.7 Legislation To comply with statutory legal requirements. Health records and associated clinical information are released to patients, their representatives and legal bodies in accordance with relevant and current legislation. The Head of Health Records Services/Senior Health Records Managers are responsible for the processing and release of clinical information in accordance with NHS Tayside Health Records Service Operating Procedures (see Appendix 5 to the NHS Tayside Health Records Management Policy) Training To provide training and guidance on legal and ethical responsibilities and operational good practice for all staff involved in health records management. Effective health records management involves staff at all levels. Training and guidance enables staff to understand and implement policies and facilitates the efficient implementation of good record keeping practices (see Appendix 3 to the NHS Tayside Health Records Management Policy) Improvement/Development Programme To ensure all national standards are employed to manage health records throughout NHS Tayside. A rolling programme of audit and performance indicators is used to identify service development needs. The National Information Governance Standards relating to health records and data quality can be viewed at The standards applicable to health records are attached appropriately listed by the categories used in the NHS Records Management: Code of Practice (Scotland) 2010 and detailed in the Improvement Plan (see Appendix 4 to the NHS Tayside Health Records Management Policy) Integrated Care Record To move towards the delivery of an integrated health record jointly managed by patients and NHS staff. This will reflect and support the National Strategic Direction as outlined in the Records Management: NHS Code of Practice (Scotland) The Code of Practice emphasises that the challenge of moving from manual to the vision of electronic integrated care records built on modern technology will require the application of the skills and experience of health records practitioners and personnel E-Health Strategy To move towards an electronic patient record summary available from various IT sources through the clinical portal. This will reflect and support the National Strategic Direction as outlined in the Records Management: NHS Code of Practice (Scotland) To meet this objective the undernoted services are available/being implemented:: clinical portal, including single sign on; electronic referral service from all GP Practices in Tayside & North East Fife including vetting on screen by secondary care clinicians; electronic data transfer service to all GP Practices in Tayside & North East Fife; discharge documentation service; electronic test requesting; pharmacy care plans; clinical document store; healthcare domain. docs_ doc Page 8 of 85

9 NHS Tayside Health Records Service Operating Procedures to provide clear and effective operating procedures for all NHS Tayside staff handling health records. Tayside Health Records Service has in place a set of standard operating procedures which cover the key areas of records practices identified in the Records Management: Code of Practice (Scotland) These incorporate best practice and provide specific guidance to staff working with health records (see Appendix 5 to the NHS Tayside Health Records Management Policy). REFERENCE National Information Governance Standards docs_ doc Page 9 of 85

10 SECTION 2 HEALTH RECORDS MANAGEMENT POLICY 2.1 INTRODUCTION 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 reaction, all the way through their lifecycle to their eventual disposal The Records Management: NHS Code of Practice (Scotland) outlined in CEL 31 (2010) has been published by the Scottish Government 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 Scotland. It is based on current legal requirements and professional best practice NHS Tayside s 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, managerial decision-making, clinical care, protect the interest of NHS Tayside and the rights of patients, staff and members of the public. They ensure consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways NHS Tayside has adopted this Health Records Management Policy and is committed to ongoing improvement of its health records management functions as it believes that it will gain a number of organisational benefits from so doing in order to support : patient care and the continuity of care; day-to-day corporate activities which underpin delivery of care; evidence based practice; epidemiology; medical and other audits improvements in clinical effectiveness through research and meet legal requirements and regulatory requirements; NHS Tayside also believes that its internal management processes will be improved by the greater availability of information that will accrue by the recognition of health records management as an integrated service across Tayside This document sets out a framework within which the staff responsible for managing NHS Tayside health records can develop specific policies and procedures to ensure that records are managed and controlled effectively, represents best value, and are commensurate with legal, operational and information needs This policy document should be read in conjunction with NHS Tayside Records Management Strategy which sets the direction for records management throughout Tayside. 2.2 SCOPE AND DEFINITIONS This policy relates to all NHS Tayside patients personal health records, held in all formats, in all locations used by NHS Tayside staff. These include: patient health records for all specialties (electronic, microfilm and paper based); radiology and imaging reports, photographs and other images; computer databases, output and disks, etc., and all other electronic records. audio and video tapes, cassettes, CD ROM etc; material intended for short term or transitory use including notes and spare copies of documents. docs_ doc Page 10 of 85

11 The health record is structured in order to contain sufficient information to identify the patient, provide a clinical history, and detail any investigations, treatments and medications Records Management is a discipline which utilises an administrative system to direct and control the 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 service the operational needs of NHS Tayside 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 appraisal; archiving; Disposal The term Records Life Cycle describes the life of a record from its creation/ receipt through the period of its active use, then into a period of inactive retention such as closed/archive files which may still be referred to occasionally, then finally either confidential disposal or archival preservation In this policy, Records are defined as recorded information, in any form, created or received and maintained by NHS Tayside in the transaction of its business or conduct of affairs and kept as evidence of such activity Information is a corporate asset. NHS Tayside health records are important sources of clinical, administrative, evidential and historical information. They are vital to NHS Tayside to support its current and future operation (including meeting the requirements of Freedom of Information legislation), for the purpose of accountability and for an awareness and understanding of the history of the care and procedures provided to patients. 2.3 AIMS OF OUR HEALTH RECORDS MANAGEMENT SYSTEM The aims of our Health Records Management System are to ensure that:- Health records are available when needed from which NHS Tayside is able to form a reconstruction of activities or events that have taken place. Health records 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. Health records can be interpreted the context of the record can be interpreted, who created or added to the record and when, during which clinical process and how the record is related to other records. Health records can be trusted the record reliability represents the information that was actually used in or created by the clinical process and its integrity and authenticity can be demonstrated. Health 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. Health 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 remains readable for as long as the records are required. Health 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. docs_ doc Page 11 of 85

12 NHS Tayside staff is trained so that all staff are made aware of their responsibilities for record-keeping and record management. Health Records Management System is supported by the provision of separate specific operating procedures relating to the key components of records management. 2.4 LEGAL AND PROFESSIONAL OBLIGATIONS All NHS records are Public Records under the Public Records Acts. NHS Tayside will take actions as necessary to comply with the legal and professional obligations set out in the Records Management NHS Code of Practice, in particular: Public Records (Scotland) Act 1937 Medical Reports Act 1988 Computer Misuse Act 1990 Access to Health Records Act 1990 Data Protection Act 1998 Human Rights Act 2000 Freedom of Information Act 2000 Common Law Duty of Confidentiality Scottish Government Records Management: NHS Code of Practice (Scotland) 2010 Quality Improvement Scotland Standards for Record Keeping Information Governance Standards National e-health Strategy ISD Data Definitions and Standards and any new legislation affecting records management as it arises. 2.5 HEALTH RECORDS SERVICE RESPONSIBILITIES NHS Tayside s Health Records Service is responsible for three main distinct functions, namely:- The management of comprehensive records library services across Tayside. The management of the release of clinical information relating to patients. The provision of Scottish Morbidity Records (SMR schemes) to the Information and Statistics Division (SD)/central Scottish Government on behalf of NHS Tayside. These major service activities are outlines in Appendix ROLES AND RESPONSIBILITIES NHS Tayside Health Board has specific responsibility for ensuring that it corporately meets its legal responsibilities and for the adoption of internal and external information governance requirements Chief Executive the Chief Executive has overall responsibility for records management within NHS Tayside. As the accountable officer he is responsible for the management of the organisation and for ensuring appropriate mechanisms are in place to support service delivery and continuity. Health records management is key to this, as it will ensure appropriate accurate clinical information is available as required Caldicott Guardian NHS Tayside s Caldicott Guardian, the Medical Director, has specific responsibility for reflecting patients interests regarding the use of patient identifiable information. He is responsible for ensuring patient identifiable information is shared in an appropriate and secure manner Health Records Committee is responsible for ensuring a high quality health records service within NHS Tayside. docs_ doc Page 12 of 85

13 2.6.5 Head of Health Records Service/Senior Health Records Managers/Information Governance Committee collectively, these are responsible for ensuring that this policy is implemented through the Records Management Strategy and that the records management system processes are developed, co-ordinated, audited and reported. An updated health records inventory will be maintained by the Senior Health Records. This will identify all health records that exist within NHS Tayside (see appendix 6) Health Records Managers are responsible for the overall development and maintenance of health records management practices throughout NHS Tayside, in particular for drawing up guidance for good records management practice and promoting compliance with this policy in such a way as to ensure the easy, appropriate and timely retrieval of patient information Clinical staff all NHS Tayside clinical staff are responsible for the secure manner in which health records are stored and handled whilst in their services. They are responsible for keeping information within the record up to date and ensuring all documentation is filed securely and accurately within the patient s personal health record Nursing staff (including ward assistants) all NHS Tayside nursing and ward assistant staff are responsible for keeping records secure and confidential whilst they are using them on the ward. They are responsible for keeping information within the record up to date and ensuring all nursing records are filed securely within the patient s personal health record Local Service Managers and Heads of Departments all NHS Tayside s clinical/administrative service/departmental managers have devolved responsibility for any health records held by their services. Heads of Departments, other units and business functions within NHS Tayside have overall responsibility for the management of health records generated by their activities, i.e., for ensuring that records controlled within their unit are managed in a way which meets the aims of the NHS Tayside Records Management policies. It is also the responsibility of these staff to ensure that the records inventory is in place, regularly updated and provided to the Senior Health Records Manager to form part of NHS Tayside s overall health records inventory All Staff all NHS Tayside staff, whether clinical or administrative, who create, receive, use or handle health records have records management responsibilities. In particular all staff must ensure that they manage and transport those health records in keeping with this policy and with any guidance subsequently produced Health Records Service Management current arrangements for the management of the service are summarised in the organisational chart attached as Appendix 2. (These arrangements are currently under review.) 2.7 RETENTION AND DISPOSAL SCHEDULES It is a fundamental requirement that all of NHS Tayside s health records are retained for a minimum period of time for legal, operational, research and safety reasons. The length of time for retaining records will depend on the type of record and its importance to the NHS Tayside business functions NHS Tayside has adopted the minimum retention periods set out in the Scottish Government Records Management: NHS Code of Practice (Scotland). The locally agreed retention schedule of standard retention periods can be found in Section 3 and will be reviewed every three years or earlier in light of legislative or Scottish Government changes. docs_ doc Page 13 of 85

14 2.8 RECORDS MANAGEMENT SYSTEM AUDIT NHS Tayside will regularly audit its records management practices for compliance with this framework The audit will:- Identify areas of operation that are covered by NHS Tayside policies and identify which procedures and/or guidance should comply with the policy. Follow a mechanism for adapting the policy to cover missing areas if these are critical to the creation and use of records and use a subsidiary development plan if there are major changes to be made. Set and maintain standards by implementing new procedures including obtaining feedback where the procedures do not match the desired levels of performance. Highlight where non-conformance to the procedures is occurring and suggest a tightening of controls and adjustment to related procedures The results of audits will be reported to NHS Tayside Board to take appropriate decisions/actions in conjunction with Health Records Service Management. 2.9 TRAINING All NHS Tayside staff will be made aware of their responsibilities for health record-keeping and health record management through generic and specific training programmes and guidance. Training and support will be provided from the Health Records Service to enable all staff to meet statutory requirements, see Appendix IMPROVEMENT PLAN To ensure that Health Records Management and records usage in Tayside meets the national quality, legislative and administrative standards. A High Level Improvement Plan is outlined in Appendix 4 and specifies key areas of improvement. Each service area should implement a local improvement plan STANDARD OPERATING PROCEDURES The current list of Service Operating Procedures for Health Records Management in NHS Tayside is attached at Appendix REVIEW This policy will be reviewed annually but the first review will be 6 months from implementation The policy may require additional review as any new or changes to codes of practice or national standard are introduced. docs_ doc Page 14 of 85

15 SECTION 3 NHS TAYSIDE : HEALTH RECORDS SERVICE Retention and Disposal Schedules THE MANAGEMENT, RETENTION AND DISPOSAL OF PERSONAL HEALTH RECORDS ANNEX D OF THE RECORDS MANAGEMENT: CODE OF PRACTICE (SCOTLAND) INTRODUCTION Scope of Schedule This Annex sets out the minimum periods for which the various personal health records created within the NHS or by predecessor bodies should be retained (in line with Principle 5 of The Data Protection Act 1998), either due to their ongoing administrative value or as a result of statutory requirement. It also provides guidance on dealing with records which have ongoing research or historical value and should be selected for permanent preservation as archives and transferred to an appropriate archive. The Annex provides information and advice about all personal health records commonly found within NHS organisations. The retention schedules apply to all the records concerned, irrespective of the format (e.g. paper, databases, s, X-rays, photographs, CD- ROMs) in which they are created or held. This Annex does not provide specific guidelines on determining which documents are retained as part of a personal health record. However, in Addendum 1, principles to be used in determining policy regarding the retention and storage of essential maternity records are set out. In addition, NHS organisations are reminded that good practice suggests that a policy determining which documents should remain in the record after discharge (or culling) should be in place. The development of such a policy should include addressing any clinical requirements for completeness of information, as well as the legal requirements of the Data Protection Act 1998, which states that only personal information which is relevant and not excessive should be retained. The Annex does not include minimum retention periods for administrative records commonly found within NHS organisations. Guidance on corporate (i.e. administrative, non-health) records is given in Annex E of the Code of Practice. 'The Management, Retention and Disposal of Administrative Records' Responsibilities and Decision Making NHS Boards are public authorities in terms of the Freedom of Information (Scotland) Act 2002, and their records are covered by the provisions of that Act and its Code of Practice on Records Management (under section 61 of the Act). For an NHS organisation to manage its records effectively, wider records management responsibilities need to be considered, placed with the appropriate individuals and/or committees, and resourced. For example, organisations may require local records managers and/or a corporate records manager; a health or medical records manager and/or committee; and an archivist. In addition, NHS Boards are required to comply with the Information Governance standards set out in the Clinical Governance and Risk Assessment standards specified by NHS Quality Improvement Scotland. These include standards applicable to administrative and patient records. docs_ doc Page 15 of 85

16 3.1.3 Retention Periods Each organisation must produce its own retention schedule, specifying the locally agreed retention periods, in the light of its own internal requirements. Organisations must not apply to any records a shorter retention period than the minimum set out in this schedule, but there may be circumstances in which they need to apply a longer retention period. Organisations should ensure that they are able to justify, particularly in terms of the Data Protection Act when applicable, the retention of records for longer than the minimum period set out in this schedule. NHS Boards and GPs as producers of products and equipment are affected by the provisions of the Consumer Protection Act 1987 covering the liability of producers for defective products. They may also be liable in certain circumstances as suppliers and users of products. An obligation for liability lasts for 10 years and within this period the Prescription and Limitation (Scotland) Act 1973, as amended by the Consumer Protection Act 1987, provides that the pursuer must commence any action within 3 years' from the date on which the pursuer was aware of the defect and aware that the damage was caused by the defect. This means that if a defective product was likely to have affected the health of a patient, then the patient's record would have to be retained for at least 13 years'. It will be for Boards and GPs to make their own judgement in such cases on whether any health records should be retained for this minimum period in order to defend any action brought under the Consumer Protection Act 1987 Organisations should ensure that they have mechanisms in place to identify records for which the appropriate minimum retention period has expired, in line with the fifth principle of the Data Protection Act It is acknowledged that organizations will have different mechanisms available to them in order to do this, and that these may vary depending on the medium on which the record is held. In relation to paper records in particular, it is acknowledged that organisations may 'batch' records together e.g. on an annual basis, in order to make disposal decisions. In such instances one approach to the calculation of minimum retention periods would be to base it on the beginning of the year after the last date on the record. For example, a file in which the first entry is in February 2001 and the last in September 2004, and for which the retention period is six years, would be kept in its entirety at least until the beginning of Disposal and Destruction of Personal Health Records a. Decision Making Staff in the operational area that ordinarily uses the records will usually be able to decide on their disposal and/ or destruction. Operational managers are responsible for making sure that all records are periodically and routinely reviewed to determine what can be disposed of or destroyed in the light of local and national guidance. In respect of personal health records, the NHS Scotland Information Governance Standards require that NHS Boards establish a Patient Records Committee, which makes decisions on policy matters and which includes representation from clinical and non-clinical staff, and which is linked appropriately to other Information Governance Groups. Input from local healthcare professionals should be a key element of any records management strategy. Once the appropriate minimum period has expired, the need to retain records further for local use should be reviewed periodically. Because of the sensitive and confidential nature of such records and the need to ensure that decisions on retention balance the interests of professional staff, including any research in which they are or may be engaged, and the resources available for docs_ doc Page 16 of 85

17 storage, it is recommended that the views of the profession's local representatives should be obtained. b. Disposal and Destruction At the end of the relevant minimum retention period, one or more of the following listed actions will apply: 1. Review: records may need to be kept for longer than the minimum retention period due to ongoing administrative and/ or clinical need. As part of the review, the organisation should have regard to the fifth principle of the Data Protection Act 1998, which requires that personal data is not kept longer than is necessary. If it is decided that the records should be retained for a period longer than the minimum the internal retention schedules will need to be amended accordingly and a further review date set. Otherwise, one of the following will apply: 2. Transfer to or consult an NHS archivist or The National Archives of Scotland (see 'Archives' section below): if the records have no ongoing administrative value but have, or may have, long-term historical or research value.. Organisations that do not have their own archivist should consult an NHS Archivist or the National Archives of Scotland for advice. 3. Destroy: where the records are no longer required to be kept due to statutory requirement or administrative or clinical need, and they have no long-term historical or research value. In the case of personal health records, this should be done in consultation with clinicians in the organisation and archivists, with the necessary arrangements made to protect patient confidentiality where appropriate. It is important that records of destruction of health records contained in this retention schedule are retained permanently. No surviving health record dated 1948 or earlier should be destroyed. Organisations should also remember that records containing personal information are subject to the Data Protection Act Archives All records management procedures with respect to NHS records, especially those that may be candidates for permanent preservation because of their wider medical or historical importance, should be informed by advice from the appropriate NHS Archivist or the National Archives of Scotland. (See the attached list of useful contacts in Annex B.) Every NHS Board should have access to the services of a professional archivist. A number of NHS Boards employ qualified archivists to look after their non-current health records and to make them available both to staff of the employing authority and members of the public in consultation with the Keeper of the Records of Scotland. In the case of Boards that do not have their own archivist, an NHS Archivist or the National Archives of Scotland will offer advice on request. Where possible, the Schedule identifies those records likely to have permanent research and historical value. Beyond this, some NHS organisations will have particular and individual reasons, which relate to their own history, for retaining particular records as archives. Conversely, it should also be borne in mind that some records may have a long-term research value outside the NHS organisation that created them (e.g. both administrative and personal health records from a number of docs_ doc Page 17 of 85

18 different hospitals have been used to study the 1918 influenza epidemic). 3.2 INTERPRETATION OF THE SCHEDULE The following types of record are covered by this retention schedule (regardless of the media on which they are held, including paper, electronic, images and sound, and including all records of NHS patients treated on behalf of the NHS in the private health sector): personal health records (electronic or paper-based, and concerning all specialties, including GP medical records); records of private patients seen on NHS premises; Accident and Emergency, birth and all other registers; theatre, minor operations and other related registers; x-ray and imaging reports, output and images; photographs, slides and other images; microform ( i.e. microfiche/ microfilm); audio and video tapes, cassettes, CDROMS etc; s; records held on computer; and scanned Documents. The layout and some of the content of the schedule is based on that published by the Department of Health on 30 March 2006 in its publication: 'Records Management: NHS Code of Practice' (270422/2/Records Management: NHS Code of Practice Part 2). Find out more here The Schedule is organised into a table with 3 headings: RECORD TYPE: lists alphabetically records created as part of a particular function. MINIMUM RETENTION PERIOD: specifies the shortest period of time for which the particular type of record is required to be kept. This period of time is usually set either because of statutory requirement or because the record may be needed for administrative purposes during this time. If an organisation decides that it needs to keep records longer than the recommended minimum period, it can vary the period accordingly and record the decision on its own retention schedule. In this regard, however, organisations must consider the fifth principle of the Data Protection Act 1998, i.e. that personal data should not be retained longer than is necessary. NOTE: - provides further information, such as whether the record type is likely to have long-term research or historical value. The following 'standard' retention periods apply to the following main record types. NHS TAYSIDE will comply with the minimum retention period as laid down by the Code of Practice (see Service Operating Procedure 1 for further information). The main record types plus the local exceptions are detailed below (for all other health record types see paragraph 3):- Record Type Adult Maternity (all obstetric and midwifery records, including those episodes of maternity care that end in stillbirth or where the child later dies). All types of records relating to Children and young people (including children's and young person's Mental Health Records) Minimum NHS Retention Period 6 years after date of last entry or 3 years after death if earlier 25 years after the birth of the last child. Retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment, or 3 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain for a longer period. docs_ doc Page 18 of 85

19 Record Type Mentally disordered person (within the meaning of any Mental Health Act) Local Exceptions Minimum NHS Retention Period 20 years after date of last contact between the patient/ client/ service user and any health/ care professional employed by the mental health provider, or 3 years after the death of the patient/ client/ service user if sooner and the patient died while in the care of the organisation. N.B.NHS organisations may wish to keep mental health records for up to 30 years before review. Records must be kept as complete records for the first 20 years in accordance with this retention schedule but records may then be summarised and kept in summary format for the additional 10-year period. Social services records are retained for a longer period. Where there is a joint mental health and social care record, the higher of the two retention periods should be adopted. When the records come to the end of their retention period, they must be reviewed and not automatically destroyed. Such a review should take into account any genetic implications of the patient's illness. If it is decided to retain the records, they should be subject to regular review. No surviving health record dated 1948 or earlier should be destroyed. Where the deceased is a child, i.e., under 16 years of age retain for 10 years after death. Where there has been a diagnosis of cancer retain for lifetime of patient. Where the patient has had cardiac surgery retain for lifetime of patient. Where there is a retention sticker retain for period specified on sticker. Throughout this Schedule, where the 'standard' retention period specified above applies, the relevant record type has the entry 'Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above)' in the 'Minimum Retention Period' column. Where it does not apply, the required minimum retention period is listed in the 'Minimum Retention Period' column. 3.3 HEALTH RECORDS RETENTION SCHEDULE - ALL RECORD TYPES Record Type Minimum NHS Retention Period Adult All types of records relating to Children and young people (including children's and young person's Mental Health Records) Mentally disordered person (within the meaning of any Mental Health Act ) 6 years after date of last entry or 3 years after death if earlier Retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment, or 3 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain for a longer period. 20 years after date of last contact between the patient/ client/ service user and any health/ care professional employed by the mental health provider, or 3 years after the death of the patient/ client/ service user if docs_ doc Page 19 of 85

20 sooner and the patient died while in the care of the organisation. N.B.NHS organisations may wish to keep mental health records for up to 30 years before review. Records must be kept as complete records for the first 20 years in accordance with this retention schedule but records may then be summarised and kept in summary format for the additional 10-year period. Social services records are retained for a longer period. Where there is a joint mental health and social care record, the higher of the two retention periods should be adopted. When the records come to the end of their retention period, they must be reviewed and not automatically destroyed. Such a review should take into account any genetic implications of the patient's illness. If it is decided to retain the records, they should be subject to regular review. Throughout this Schedule, where the 'standard' retention period specified above applies, the relevant record type has the entry 'Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above)' in the 'Minimum Retention Period' column. Where it does not apply, the required minimum retention period is listed in the 'Minimum Retention Period' column. Health Records Retention Schedule TYPE OF HEALTH RECORD MINIMUM RETENTION PERIOD NOTE A&E records (where these are stored separately from the main patient record) A&E registers (where they exist in paper format) Abortion - Certificates set out in Schedule 1 to the Abortion (Scotland) Regulations 1991 Admission books (where they exist in paper format) Ambulance records - patient identifiable Component (including paramedic records made on behalf of the Ambulance Service) Asylum seekers and refugees ( NHS personal health record - patient held record) Audiology records Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) 8 years after the year to which they relate. 3 years beginning with the date of the termination 8 years after the last entry 7 years Special NHS record- patient held, no requirement on the NHS to retain. Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) Likely to have archival valuesee footnote Likely to have archival valuesee footnote Birth registers (ie register of births kept by the hospital) 2 years Likely to have archival valuesee footnote docs_ doc Page 20 of 85

21 Body release forms Breast screening Xrays Cervical screening slides Chaplaincy records Child and family guidance Child Protection Register (records relating to) Clinical audit records Clinical psychology Clinical trials of investigational medicinal products - health records of participants that are the source data for the trial Counselling records Death - Cause of, Certificate counterfoils Death registers - i.e. register of deaths kept by the hospital, where they exist in paper format Dental epidemiological surveys Dental, ophthalmic and auditory screening records 2 years 8 years 10 years 2 years Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) Retain until the patient's 26th birthday 5 years 30 years For trials to be included in regulatory submissions: At least 2 years after the last approval of a marketing application in the EU. These documents should be retained for a longer period, however, if required by the applicable regulatory requirement(s) or by agreement with the Sponsor. It is the responsibility of the Sponsor/someone on behalf of the Sponsor to inform the investigator/institution as to when these documents no longer need to be retained. For trials which are not to be used in regulatory submissions: At least 5 years after completion of the trial. These documents should be retained for a longer period if required by the applicable regulatory requirement(s), the Sponsor or the funder of the trial, In either case, if the period appropriate to the specialty is greater, this is the minimum retention period. 30 years 2 years 2 years 30 years Adults: 11 years Children: 11 years, or up to 25th birthday, whichever is the longer Likely to have archival valuesee footnote Likely to have research value see footnote Likely to have research/ historical value see footnote Likely to have archival valuesee footnote Diaries - health visitors and district nurses 2 years after end of year to which diary relates. Patient relevant information should be It is not good practice to record patient identifiable docs_ doc Page 21 of 85

22 transferred to the patient record. information in diaries. Dietetic and nutrition Discharge books (where they exist in paper format) District nursing records Donor records (blood and tissue) Family planning records Forensic medicine records (including pathology, toxicology, haematology, dentistry, DNA testing, post mortems forming part of the Procurator Fiscal's report, and human tissue kept as part of the forensic record) See also Human tissue, Post mortem registers Genetic records Genito Urinary Medicine ( GUM) GP records, including medical records relating to HM Armed Forces Retain according to the standard minimum retention period appropriate to the patient/ specialty(see above) 8 years after the last entry Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) 30 years post transplantation 10 years after the closure of the case For children retain until their 25 th Birthday For post mortem records which form part of the Procurator Fiscal's report, approval should be sought from the PF for a copy of the report to be incorporated in the patient's notes, which should then be kept in line with the specialty, and then reviewed. In cases where criminal proceedings are anticipated documentation is not normally entered in to the patient records. All other records retain for 30 years. 30 years from date of last attendance. Store according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Retain for the lifetime of the patient and for 3 years after their death. Records relating to those serving in HM Armed Forces - The Ministry of Defence (MoD) retains a copy of the records relating to service medical history. The patient may request a copy of these under the Data Protection Act ( DPA), and may, if they choose, give them to their GP. GPs should also receive summary records when ex-service personnel register with them. What GPs do with them is a matter for their professional judgement, taking into account clinical need and Data Protection Act requirements- they should not, for example, retain information that is not relevant to their Likely to have archival valuesee footnote Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote *The rationale for this is explained in ' SCIMP Good Practice Guidelines for General Practice Electronic Patient Records - section 6.1' docs_ doc Page 22 of 85

23 clinical care of the patient. GP records of serving military personnel in existence prior to them enlisting must not be destroyed. Following the death of the patient the records should be retained for 3 years. *Electronic Patient Records ( EPRs)- GP onlymust not be destroyed, or deleted, for the foreseeable future 10 years Health visitor records Records relating to children should Homicide/ 'serious untoward incident' records Hospital acquired infection records Human fertilization records, including embryology records Human tissue (within the meaning of the Human Tissue (Scotland) Act 2006) (see Forensic medicine above) be retained until their 25th birthday 30 years 6 years Treatment Centres 1. If a live child is not born, records should be kept for at least 8 years after conclusion of treatment 2. If a live child is born, records shall be kept for at least 25 years after the child's birth 3. If there is no evidence whether a child was born or not, records must be kept for at least 50 years after the information was first recorded Storage Centres Where gametes etc have been used in research, records must be kept for at least 50 years after the information was first recorded. Research Centres Records are to be kept for 3 years from the date of final report of results/ conclusions to Human Fertilisation and Embryology Authority ( HFEA) For post mortem records which form part of the Procurator Fiscal's report, approval should be sought from the Procurator Fiscal for a copy of the report to be incorporated in the patient's notes, which should then be kept in line with the specialty, and then reviewed. Likely to have research/ historical value see footnote Likely to have research value see footnote Likely to have research value see footnote docs_ doc Page 23 of 85

24 Intensive Care Unit charts Joint replacement records Learning difficulties -(records of patients with) Macmillan (cancer care) patient records -community and acute Maternity (all obstetric and midwifery records, including those of episodes of maternity care that end in stillbirth or where the child later dies) Medical illustrations (see Photographs below) Mentally disordered persons (within the meaning of any Mental Health Act) Microfilm/ microfiche records relating to patient care Midwifery records Mortuary registers (where they exist in paper format) Music therapy records Neonatal screening records Notifiable diseases book Occupational Health Records (staff) Health Records for classified persons under medical surveillance Retain according to the standard minimum retention period appropriate to the patient/specialty (see above) For joint replacement surgery the revision of a primary replacement may be required after 10 years to identify which prosthesis was used. Only need to retain minimum of notes with specific information about the prosthesis. Retain for 3 years after the death of the individual. Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) 25 years after the birth of the last child Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) 25 years after the birth of the last child 10 years Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) 25 years 6 years 6 years after termination of employment 50 years from the date of the last entry or age 75, whichever is the longer Likely to have research value see footnote Likely to have archival value- see footnote Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote docs_ doc Page 24 of 85

25 Personal exposure of an identifiable employee monitoring record Personnel health records under occupational surveillance Radiation dose records for classified persons Occupational therapy records Oncology (including radiotherapy) Operating theatre registers Orthoptic records Out of hours records ( GP cover), including video, DVD and tape voice recordings Outpatient lists (where they exist in paper format) Parent held records Sexual Health Records 40 years from exposure date 40 years from last entry on the record 50 years from the date of the last entry or age 75, whichever is the longer Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) 30 years N.B. Records should be retained on a computer database if possible. Also consider the need for permanent preservation for research purposes. 8 years after the year to which they relate Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) 2 years after the year to which they relate There should be a copy kept at the NHS organisation responsible for delivering that care and compiling the record of the care. The records should then be retained until the patient's 25th birthday, or 26th birthday if the young person was 17 at the conclusion of treatment, or 3 years after death No national guidance in the code of practice exists for Sexual Health Records. The records inventory survey will establish current practice, type of records held and retention guidance. A request has been raised nationally for guidance to be included within the revision of the this policy. Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote Likely to have research value see footnote Likely to have historical valuesee footnote docs_ doc Page 25 of 85

26 Pathology records: Documents, electronic and paper TYPE OF HEALTH RECORD MINIMUM RETENTION PERIOD NOTE Accreditation documents; records of Inspections Batch records results Bound copies of reports / records, if made Correspondence on patients Day books and other records of specimens received by a laboratory Equipment/ instruments maintenance logs, records of service inspections Procurement, use, modification and supply records relevant to production of products (diagnostics) or equipment External quality control Records Internal quality control Records Lab file cards or other working records of test results for named patients Mortuary Registers Near-patient test data Pathological archive/museum catalogues Photographic records 10 years or until superseded 10 years 30 years This should be lodged in the patient's record, if feasible. However this is often beyond the control of the laboratory, particularly for case referred distantly, and ensuring entry into the patients notes is not primarily the responsibility of laboratory staff. Otherwise, keep for at least 30 years; this may be most conveniently done in association with stored paper or scanned copy of the relevant specimen request and/ or report kept by the relevant laboratory. 2 years from specimen receipt Lifetime of instrument; minimum of 10 years Comprehensive records relevant to procurement, use, modification and supply: 10 years. Subscribing laboratories or individuals, 5 years to ensure continuity of data available for laboratory accreditation purposes. Records will be kept for longer periods by organisations providing external quality assessment schemes. 10 years 1 year from specimen receipt if all results transcribed into a separately issued and stored formal report. Otherwise, they should be kept as for worksheets over. The diversity of these types of working records is very wide; within specialties and departments, consideration should be given to the potential audit or medico- legal value of storing such working records for 30 years, as for other primary records. 30 years Result in patient record, log retained for lifetime of instrument For as long as the specimens are held or until the catalogue is updated, subject to consent where required, (with maintained and accessible documentation of consent) Where images represent a primary source of information for the diagnostic process, whether conventional photographs or digital images, they should be kept for at least 30 years. docs_ doc Page 26 of 85

27 Records of telephoned Reports Records relating to cell/ tissue transplantation Records relating to investigation or storage of specimens relevant to organ transplantation, semen or ova Reports and copies (physical or electronic) Reports, copies Post mortem reports Request forms that are not a unique record Request forms that contain clinical information not readily available in the health record Standard operating procedures (both current and outdated protocols) Note of the fact and date/ time that a telephone or fax report has been issued should be added to the laboratory electronic records of the relevant report, or to hard copies and kept for a minimum of 5 years. Where management advice is discussed in telephone calls, a summarised transcript should be retained long term, as for the retention of other correspondence. Clinical information or management advice provide by fax, in addition of pure transmission of report, should also be kept as correspondence in the patient note and/ or stored with a laboratory copy of the specimen request/ report for 30 years. Records not otherwise kept or issued to patient records that relate to investigations or storage of specimens relevant to cell/ tissue transplantation, including donated organs from deceased individuals should be kept for at least 30 years or the lifetime of the recipient, whichever is the longer. 30 years if not held with health record 6 months or as needed for operational procedures. Where copies represent a means of communication or aide memoire, for example at a multi- disciplinary meeting or case conference, they may be disposed of when that function is complete. Copies of reports sent by fax, with accompanying details of the date and times of transmission, and the intended recipient, should be retained in conjunction with the matching specimen reports and stored long-term by the laboratory. Any such copies generated to substitute for an original report ( e.g. if an original is misplaced) should be retained as for the original. The report should be lodged in patient's record; in the case of Procurator Fiscal reports this is dependant on the PF's approval. Electronic or hard copy should be kept at least 30 years with maintained accessibility. In addition to accessible indexing of paper copies, there must be continuation of access to e-copies when laboratory, computer systems are upgraded or replaced. This guidance applies equally to rapid, short reports that maybe prepared for the PF, summarising cause of death and to the final reports of post-mortem examinations. Request forms should be kept until the authorised report, or reports on investigation arising from it, have been received by the requestor. As this period of time may vary with local circumstances, no minimum retention time is recommended, request forms need not to be kept for more than one month after the final checked report has been despatched. For many uncomplicated requests, retention of 1 week will suffice. 30 years Where the request form is used to record working notes or as a worksheet, it should be retained as part of the laboratory record. 30 years docs_ doc Page 27 of 85

28 Surgical (histological) reports Copy lodged in patients notes. Electronic or hard copy to be kept for at least 30 years by the laboratory with maintained accessibility of e- copies when laboratory, computer systems are upgraded or replaced. Pathology Records: Specimens and Preparations. TYPE OF HEALTH RECORD Body fluids/ aspirates/ swabs Blocks for electron microscopy Electrophoretic strips and immunofixation plates Foetal serum Frozen tissue for immediate histological assessment (frozen section) Frozen tissues or cells for histochemical or molecular genetic analysis Grids for electron microscopy Human DNA Microbiological cultures Museum specimens (teaching collections) Newborn blood spot screening cards Paraffin blocks MINIMUM RETENTION PERIOD Keep for 48 hours after the final report has been issued by the laboratory, unless sample deterioration precludes storage. 30 years Keep for 5 years, unless digital images are taken, if digital images of adequate quality for diagnosis are taken, then the original preparations may be discarded after 2 years. The images should then be stored under "photographic records" bearing in mind the need to maintain the ability to read archived digital images when equipment is updated. Because of it's rarity and value for future research, wherever possible foetal serum should be kept for at least 30 years. Stained microscope slides should be kept for a minimum of 10 years. 10 years and preferably longer if storage facilities permit. Requirements in different specialties differ. Grids prepared for human tissue diagnosis ( e.g. renal, muscle, nerve, or tumour) should be kept for 10 years; preferably longer if practicable. Grids prepared for virus identification maybe discarded 48 hours after the final report has been issued, provided that all derived images are retained and remain accessible for at least 30 years. 4 weeks after final report for diagnostic specimens. 30 years for family studies for genetic disorders (consent required) days after final report of a positive culture issued. 7 days for certain specified cultures- see RCPath document Permanently. Consent of the relative is required if it is tissue A minimum of 5 years storage is indicated for quality assurance purposes, with longer term storage recommended in accordance with the Code of Practice of the U.K Newborn Screening Programme Centre (2005). See here for more information. Storage for at least 30 years is recommended, if facilities permit. If not, review the need for archiving at 10 years (and at similar intervals thereafter) and select representative blocks, showing the relevant pathology for permanent retention. Blocks representing rare pathologies and those (including representative normal tissue) from NOTE docs_ doc Page 28 of 85

29 patients of diseases known or thought likely to have an inherited genetic pre-disposition should be particular considered for permanent retention. Wherever possible, storage of all histology block should be for the full minimum of 30 years. Plasma and serum Records relating to donor or recipient sera Serum from first pregnancy booking visit Keep for 48 hours after the final report has been issued by the laboratory. Serum samples obtained from recipient (s) for the purposes of matching in cell/tissue transplantation, and their accompanying records, must be kept for the lifetime of the recipient. Should be kept by microbiology/ virology and other relevant laboratories to provide a baseline for further serological or other tests for infections or other disease during pregnancy and the first 12 months after delivery. Because of rarity and value to future research, wherever possible, foetal serum (from cordocentesis) should be kept for at least 30 years. Appropriate retention times depend on there nature and purpose. Relevant guidance on minimum retention periods can be found here. Stained slides Wet tissue (representative aliquot or whole tissue or organ) Whole blood samples, for full blood count Note that where sections are likely to contain intact human cells, or are intended to be representative of whole cells, they constitute "relevant material" under the Human Tissue act 2004; further information can be found here. For surgical specimens from living patients, keep for 4 weeks after issue of final report. For cases in which a supplementary report is anticipated after additional tests, (such as various molecular investigations or referral for expert opinion), which may occasionally exceed this period, arrangements should exist to ensure that individual specimens are retained until the additional report has been finalised. 24 hours Pathology Records: Transfusion Laboratories TYPE OF HEALTH RECORD MINIMUM RETENTION PERIOD NOTE Annual reports (where required by EU directive) Autopsy reports, specimens, archive material and other where the deceased has been the subject of Procurator Fiscals autopsy 15 years Procurators Fiscal have absolute dominion over autopsy reports. They are confidential to them and may not be released without their consent to any third party. It is good practise to lodge copies of the autopsy report in the deceased patients health record but the consent of the procurator fiscal should be obtained. 30 years to allow full traceability of all blood products used. Blood bank register, blood component audit trail and fates The data may be held in electronic form if robust archiving arrangements are in place. For hospital laboratories the records should include: Blood component supplier identification. docs_ doc Page 29 of 85

30 Issued blood component identification Transfused recipient identification For blood units not transfused; confirmation of subsequent disposition (discard/ other use) Lot number (s) of derived component (s) if relevant Date of transfusion or disposition (day, month and year) Blood for grouping, antibody screening and saving and/or cross-matching 1 week at 4 C Permanently- not part of the health record. Forensic material - criminal cases Refrigeration and freezer charts Request forms for grouping, antibody screening and crossmatching Results of grouping, antibody screening and other blood transfusion-related tests Separated serum/plasma, stored for transfusion purposes Storage of material following analyses of nucleic acids Worksheets In cases where criminal proceeding can be anticipated, all recording made at the autopsy, be the hand written notes (by everyone, i.e. pathologist, technician, trainee, etc), tape recordings, drawings or photographs, are all documentary records and as such their existence must be declared (disclosed). They must be available to all involved throughout the lifetime of the case, including appeals and other reinvestigations. 15 years 1 month 30 years to allow full traceability of all blood products used, in compliance with the Blood Safety and Quality Regulations No minimum storage time is recommended for recipient patient samples. Storage of donated serum/ plasma should optimally be at -30 degrees Centigrade or colder. These materials may be stored for up to 6 months, but guidelines for the timeline of sample collection prior to blood transfusion must be followed. Archived blood donor samples should be stored by blood services for at least 3 years, and preferable longer if it is practicable, in order to facilitate 'look back' exercises. Developing technologies mean that there are now a variety of hard copy and / or electronic outputs associated with the analysis and interpretation of diagnostic tests using nucleic acid. It is recommended that all such outputs should be stored for at least 30 years unless the information is transcribed into permanently accessible report formats authorised by senior clinical laboratory staff or pathologists. The later reports should be kept for at least 30 years, as for other pathology reports may be regarded as reporting documents. For such working documents storage for at least the instrument, with a minimum of 10 years is recommended. 30 years to allow full traceability of all blood products used End of Pathology Records docs_ doc Page 30 of 85

31 Patient Held Records Patient held records At the end of an episode of care the NHS organisation responsible for delivering that care and compiling the record of the care must make appropriate arrangements to retrieve patient-held records. The records should then be retained for the period appropriate to the patient/ specialty (see Above). Pharmacy Records: Prescriptions TYPE OF HEALTH RECORD Chemotherapy Clinical drug trials (nonsponsored) MINIMUM RETENTION PERIOD 2 years after last treatment 2 years after completion of trial NOTE GP10, TTO's, outpatient, private 2 years N.B. Inpatient prescriptions held as part of health record. Immunoglobulin's/ blood products Parenteral nutrition Unlicensed medicines dispensing record 30 years 2 years 5 years To allow full traceability of all blood products used Original valid prescription to be held with the health record. Pharmacy Records: Clinical trials TYPE OF HEALTH RECORD MINIMUM RETENTION PERIOD NOTE Destruction records Dispensing records Production batch records Protocols 2 years after end of trail 2 years 5 years after end of trial 2 years Pharmacy Records: Worksheets TYPE OF HEALTH RECORD MINIMUM RETENTION PERIOD NOTE Chemotherapy, aseptics worksheets, Extemporaneous dispensing records Parenteral nutrition, production batch records Production batch records Raw material request and control forms 5 years 5 years 5 years 5 years 5 years docs_ doc Page 31 of 85

32 Resuscitation box worksheet Paediatric worksheets 1 year after the expiry of the longest data item Applies only to re-packaged items. As per Children and Young People (see Above) Pharmacy Records: Quality Assurance TYPE OF HEALTH RECORD Analysis certificates Environmental monitoring results Equipment validation Operators validation QC Documentation, Refrigerator temperature Standard operating procedures MINIMUM RETENTION PERIOD 5 years or 1 year after expiry date of batch (whichever is longer) 1 year after expiry date of products Lifetime of the equipment Duration of employment 5 years or 1 year after expiry date of batch (whichever is longer) 1 year 15 years after superseded by revised version NOTE As electronic record in perpetuity Refrigerator records to be retained for the life of any product stored therein particularly vaccines As electronic record in perpetuity Pharmacy Records: Orders Adhoc forms (dispensing requests forms to store) Invoices 3 months 6 years Order and delivery notes, requisition sheets, old order books Current financial year plus one Picking tickets/ delivery notes Ward Pharmacy requests 3 months 1 year Pharmacy Records: Controlled Drugs, Others TYPE OF HEALTH RECORD Aspectic controlled drugs worksheets (paediatric) Controlled drugs, Clinical trails Controlled drug destruction records (pharmacy based)/ destruction of patients' own CD's Controlled drug prescriptions ( TTOs/ OP) 26 years 5 Years 7 years 2 years MINIMUM RETENTION PERIOD NOTE docs_ doc Page 32 of 85

33 Controlled drug order books, ward orders and requisitions Controlled drug registers (pharmacy and ward based) Copy of signature for CD ward order or requisition Extemporaneous controlled drugs preparation worksheets External controlled drug orders and delivery notes Pharmacy records: others Destruction of patients' own drugs Dispensing errors Doctors/ nurses signatures Medicines information enquiry Minor clinical interventions Recall documentation Stock check list Superseded group directions Superseded intravenous drug administration monographs 2 years from date of last entry 2 years from date of last entry, but if contain record of destruction of CD, keep for 7 years Duration of employment 13 years 2 years 6 months 1 year plus current Duration of contract plus one year 8 years (25 years for child obstetrics and gynaecology enquiries) 2 years 5 years 1 year plus current 10 years 5 years Copy of signature of each authorised signatory should be available in the pharmacy department (end of Pharmacy) docs_ doc Page 33 of 85

34 Other Health Records TYPE OF HEALTH RECORD MINIMUM RETENTION PERIOD NOTE Photographs (where the photograph refers to a particular patient it should be treated as part of the health record) Physiotherapy records Podiatry records Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) Post mortem records (see Pathology records Post mortem registers (where they exist in paper format) Private patient records admitted under section 57 of the National Health Service (Scotland) Act 1978 or section 5 of the National Health Service (Scotland) Act 1947 (now repealed) Psychology Records Records/documents related to any litigation Records of destruction of individual health records (case notes) and other health related records contained in this retention schedule (in manual or computer format) Research records 1. Other than clinical trials of investigational medicinal products, health records of participants that are the source data for the research 2. Research records and research databases (not patient specific) 30 years It would be appropriate for authorities to retain these according to the standard minimum retention period appropriate to the patient/ specialty (see above) 30 years As advised by the organisation's legal advisor. All records to be reviewed. Permanently 30 years Clinical trials of investigational medicinal products At least 2 years after the last approval of a marketing application in the EU. These documents should be retained for a longer period, however, if required by the applicable Likely to have archival value- see footnote Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote Likely to have research/ historical value see footnote See Footnote Review patient identifiable records every 5 years to see if they need to be retained or if their identifiably could be reduced. Likely to have research value see footnote docs_ doc Page 34 of 85

35 regulatory requirement(s) or by agreement with the sponsor. It is the responsibility of the sponsor/ someone on behalf of the sponsor to inform the investigator/ institution as to when these documents no longer need retained. Research records other than for clinical trials of investigational medicinal products As above. Scanned records relating to patient care School health records (see Children and young people) Speech and language therapy records Telemedicine records (see also Video records) Transplantation records Ultrasound records ( e.g. vascular, obstetric) Video records/ voice recordings relating to patient care/videoconferencing records (see also Telemedicine records and Out of hours records) Retain in main records and retain for the period of time according to the standard minimum retention period appropriate to the patient/ specialty (see above) Retain in Child Health Records Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) Records not otherwise kept or issued to patient, records that relate to investigations or storage of specimens relevant to organ transplantation should be kept for 3 years Retain according to the standard minimum retention period appropriate to the patient/ specialty (see Above) 6 years subject to the following exceptions: Children and Young People- Records must be kept until the patient's 25th birthday, if the patient was 17 at the conclusion of treatment until their 26th birthday, or until 3 years after the patient's death if sooner. Maternity- 25 years Mentally disordered persons- Records should be kept for 20 years after the date of last contact Likely to have research value see footnote The teaching and historical value of such recordings should be considered, especially where innovative procedures or unusual conditions are involved. Video/ video-conferencing records should be either permanently archived or permanently destroyed by shredding or incineration (having due regard to the need to maintain patient confidentiality) docs_ doc Page 35 of 85

36 Ward registers, including daily bed returns (where they exist in paper format) Xray films (excluding PACS images) Xray - PACS images Xray registers (where they exist in paper format) Xray reports (including reports for all imaging modalities) between patient/ client/ service user and any healthcare professional or 3 years after the patient's death if sooner. Cancer patients- Records should be kept until 6 years after the conclusion of treatment, especially if surgery was involved. The Royal College of Radiologists has recommended that such records be kept permanently where chemotherapy and/ or radiotherapy was given. 2 years after the year to which they relate The minimum retention period for these can continue to be determined locally by the NHS organisation responsible. In setting the minimum retention period, appropriate recognition should be given to current professional guidance, clinical need, special interest groups, cost of storage and the availability of storage space. National: PACS images captured as part of the national PACS programme are stored in a central national archive in accordance with the National PACS for Scotland Image Retention/ Storage Policy, which is subject to annual review by the PACS Clinical Advisory Group. Local: Locally set minimum retention periods can continue to apply to PACS images that are not captured as part of the national PACS programme. 30 years To be considered as part of the patient record. Retain according to the standard minimum retention period appropriate to the patient/ specialty (see above) Likely to have archival value- see footnote As ehealth strategic developments progress, this guidance, along with that for other record types affected, will be reviewed. Likely to have archival value- see footnote docs_ doc Page 36 of 85

37 Foot Note - record is likely to have permanent research and historical value, consult NHS archivist or National Archives of Scotland. Principles to be used in Determining Policy Regarding the Retention and Storage of Essential Maternity Records Reproduced below is the joint position on the retention of maternity records as agreed by the British Paediatric Association, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the then United Kingdom Central Council for Nursery, Midwifery and Health Visiting. This is specified in the Department of Health publication: 'Records Management: NHS Code of Practice' (270422/2/Records Management: NHS Code of Practice Part 2). Joint Position on the Retention of Maternity Records All essential maternity records should be retained. 'Essential' maternity records mean those records relating to the care of a mother and baby during pregnancy, labour and the puerperium. Records that should be retained are those that will, or may, be necessary for further professional use. 'Professional use' means necessary to the care to be given to the woman during her reproductive life, and/or her baby, or necessary for any investigation that may ensue under the Congenital Disabilities (Civil Liabilities) Act 1976, or any other litigation related to the care of the woman and/or her baby. Local level decision making with administrators on behalf of the health authority must include proper professional representation when agreeing policy about essential maternity records. 'Proper professional' in this context should mean a senior medical practitioner(s) concerned in the direct clinical provision of maternity and neonatal services and a senior practising midwife. Local policy should clearly specify particular records to be retained AND include detail regarding transfer of records, and needs for the final collation of the records for storage. For example, the necessity for inclusion of community midwifery records. The policy should also determine details of the mechanisms for the return, collation and storage of those records, which are held by mothers themselves, during pregnancy and the puerperium. List of Maternity Records to be retained Maternity Records retained should include the following: documents recording booking data and pre-pregnancy records where appropriate; documentation recording subsequent antenatal visits and examinations; antenatal inpatient records; clinical test results including ultrasonic scans, alphafeto protein and chorionic villus sampling; blood test reports; all intrapartum records to include initial assessment, partograph and associated records including cardiotocographs; drug prescription and administration records; postnatal records including documents relating to the care of mother and baby, in both the hospital and community settings. docs_ doc Page 37 of 85

38 3.4 RESOURCES TO SUPPORT IMPROVEMENT The Role of the Information Governance Framework and the Information Governance Toolkit Information Governance is defined as:- A framework for handling information in a confidential and secure manner to appropriate ethical and quality standards in a modern health service. It is the information component of Clinical Governance and it aims to support the provision of high quality care to patients and clients and service users by promoting the effective and appropriate use of personal, sensitive information. The Information Governance Framework enables NHS Boards and staff working within them, to ensure that personal information is dealt with legally, securely, effectively and efficiently. The focus is on setting standards and giving NHS Boards the tools to help them to incrementally achieve the defined requirements, make appropriate improvements to their service, which is sustained. The Information Governance Framework addresses the following key areas when handling information: Caldicott recommendations on the use of patient identifiable information; NHS Scotland Confidentiality Code of Practice; Data Protection Act 1998; Freedom of Information (Scotland) Act 2002; Information Management and Technology Security (ISO Code of Practice for Information Security Management); Health and Corporate Records Management; Information Quality Assurance. The Information Governance Framework also enables the NHS to monitor and manage change by educating staff, developing codes of practice, helping organisations and individuals to understand the requirements of law and ethics in respect of information handling and the consequent need for changes to systems and processes. Furthermore, it enables the NHS to work in partnership with patients and clients by respecting their preferences and choices and addressing their concerns about the use of sensitive, personal information. The Information Governance Toolkit provides the means by which NHS Boards can assess their compliance against the national information governance standards. The standards can be viewed here The Standards in the toolkit explain and expand upon those published in the NHS QIS Clinical Governance and Risk Management Standards, which were published in October For further information please visit here The reports produced by the toolkit will be shared with NHS QIS as part of the Clinical Governance and Risk Managements Standards peer review visits. The Department of Health has published Setting and Achieving the NHS Standards for Record Management A Roadmap. The roadmap applies to England only, but may be of interest to a Scottish audience as it contains a range of practical tools and guidance, including a knowledge base and templates that have been designed to support organisations in the implementation of the principles contained in the English version of the NHS Records Management Code of Practice. The content of the Roadmap will be reviewed and updated at regular intervals. The Roadmap is available electronically to all organisations here docs_ doc Page 38 of 85

39 Other Reference Material Good Practice Guidelines for General Practice Electronic Patient Records SCIMP Good Practice Guidelines for General Practice Electronic Patient Records for Scottish guidance on the transfer of electronic health records. Quality and Outcomes Framework (QOF) The Primary Medical Services (Scotland) Act 2004 introduced the concept of the Quality and Outcomes Framework (QOF) as a voluntary contractual requirement for participating Practices. The QOF provides a significant financial incentive to demonstrate achievement against a wide range of clinical and organisational quality standards Confidentiality and Disclosure of Information: General Medical Services The Scottish Guidance NHS Circular: PCA(M)(2005)10 Confidentiality and Disclosure of Information: General Medical Services (GMS), Section 17c Agreements, and Health Board Primary Medical Services (HBPMS) Code of Practice and Directions sets out guidance on the confidentiality of information held by contractors - referred to collectively in this document as contractors who provide General Medical Services (GMS), Section 17C Agreements and Health Board Primary Medical Services (HBPMS). Find out more here Code of Practice on Records Management - Section 61 of Freedom of Information (Scotland) Act The Scottish Ministers Code of Practice on Records Management under Section 61 of the Freedom of Information (Scotland) Act Find out more here The Code of Practice provides guidance to all public authorities as to the practice which it would, in the opinion of the Scottish ministers, be desirable for them to follow in connection with the management of records under the Freedom of Information (Scotland) Act Records Management: NHS Code of Practice (Department of Health) The Records Management: NHS Code of Practice, on which this guidance is based, was published by the Department of Health as guidance to NHS organisations in England on 30 March Find it here The National Archives of Scotland: Model Action Plan for Developing Records Management The National Archives of Scotland: Model Action Plan for Developing Records Management Arrangements Compliant with the Code of Practice on Records Management under Section 61of the Freedom of Information (Scotland) Act 2002 can be found here A records management action plan detailing the steps that health service organisations should take to reach the standards set out in the Scottish Ministers Code of Practice. The National Archives of Scotland: Developing a Policy for Managing The National Archives Guidelines on developing a policy for managing can be found Here Scottish Executive Freedom of Information Act Open Learning Workbook The Scottish Executive Freedom of Information (Scotland) Act 2002 Open Learning Workbook(2004) can be found here A workbook designed by Masons solicitors on behalf of the Scottish Executive to help public authorities with implementation of Freedom of Information. Modules 5 and 6 deal specifically with records management. The retention and storage of pathological records and archives The Royal College of Pathologists: The retention and storage of pathological records and archives (3rd edition, 2005) can be found here The document contains guidance from The Royal College of Pathologists and the Institute of Biomedical Science regarding the management of pathology records. docs_ doc Page 39 of 85

40 Designing and Implementing Records Keeping Systems (BS ISO ) BS ISO (Designing and Implementing Records Keeping Systems DIRKS) Includes an eight step approach to effective records management for organisations to follow. Information Commissioner CCTV Code of Practice The ICO has revised its existing code of practice on CCTV to reflect technological developments and changes to the way CCTV is used to monitor individuals. This revised code has now been published and is available here Information Commissioner: The Use and Disclosure of Health Data Find this document here Active Records Management: Records Creation A document that provides advice and guidance on the creation of paper-based files, it does not cover the creation of electronic files. It deals with the creation of registered files including policy, administrative and case files but not staff personal files. Find out more here e-government Technical Standards There are a number of Government standards which aim to ensure the consistency of electronic information transferred between public organisations or made available to the public through means such as websites. E-GIF is mandatory for all public sector bodies, including the NHS. Full details can be found here Health and Social Care Data Standards The National Clinical Dataset Development Programme was established by the Chief Medical Officer in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-health Strategy. Further information can be obtained from their website here and the standards are published in the Health and Social Care Data Dictionary here University of Edinburgh Records Management Section Access their site here University of Edinburgh file naming conventions This document has been prepared as part of the Policy and Planning Records Management Project and is aimed primarily at people working within Academic Affairs, Planning and Secretariat departments in higher education. However, the principles will be beneficial to all staff working with corporate records including staff in NHS organisations. Find out more here Code of Practice for Legal Admissibility and evidential weight of information stored electronically (BIP 0008: Copyright BSI) This code of practice has been published in recognition of the growth in electronic information management systems, and the continuing uncertainty about the legal acceptability of information stored on these systems. Scanning and Document Management in General Practice (May 2006) SCIMP have produced this simple guide to implementing the single scanning and document management system that has now been procured for Scottish General Practices. Educational Material NHS Scotland Data Protection and Confidentiality Training Package available here Healthcare Information Governance Post-Graduate Education Programme Unit 2 focuses on Records Management Useful Contacts Scottish NHS Archives and The National Archives of Scotland There are at present three NHS archivists providing archive services to NHS Boards in Scotland. They can provide advice on the selection and preservation of healthcare records and the management of current records. docs_ doc Page 40 of 85

41 Mike Barfoot Lothian Health Services Archive Edinburgh University Library George Square Edinburgh EH8 9LJ Tel: Alistair Tough Greater Glasgow and Clyde NHS Board Archive University of Glasgow Archives Dumbarton Road GLASGOW G11 6PW Tel: Fax: Fiona Watson Northern Health Services Archives Victoria Pavilion Woolmanhill Hospital Aberdeen AB25 1LD 32 Tel: For advice on archiving in the NHS Tayside area contact: Pat Whatley Archive, Records Management and Museum Services Tower Building University of Dundee DUNDEE DD1 4HN Tel: Alternatively, the National Archives of Scotland (NAS) can provide advice about records management and archives. NAS does not offer an archive facility to local NHS boards and organisations, but can suggest appropriate archive contacts elsewhere: National Archives of Scotland HM General Register House 2 Princes Street EDINBURGH EH1 3YY Tel: enquiries@nas.gov.uk The National Archives of the United Kingdom (TNA) published a Code of Practice for Archivists and Records Managers under Section 51(4) of the Data Protection Act 1998 in October Chapter 3 summarises the particular responsibilities of records managers in relation to personal data. Archival advice about moving images can be obtained from: Scottish Screen Archive 249 West George Street Glasgow G2 4QE Tel docs_ doc Page 41 of 85

42 Scottish Government ehealth Directorate Scottish Government ehealth Directorate St Andrews House Regent Road EDINBURGH EH1 3XD Information Commissioner Scotland Office (Data Protection Act 1998) 28 Thistle Street Edinburgh EH2 1EN Tel: Fax: Website: Scottish Information Commissioner (Freedom of Information (Scotland) Act 2002) Kinburn Castle Doubledykes Road St Andrews Fife KY16 9DS Tel: Fax: Website: NHS Scotland Information Governance Programme Information Governance Team NHS National Services Scotland Information Services Division Area 067 Gyle Square 1 South Gyle Crescent EDINBURGH EH12 9EB Tel: infogov@isd.csa.scot.nhs.uk docs_ doc Page 42 of 85

43 SECTION 4 Appendix 1 NHS TAYSIDE: HEALTH RECORDS SERVICE Major Service Activities 1. The management of comprehensive records library services across Tayside: Ensuring health records are created, retained and stored securely within the library areas. Providing health records with all supporting information for inpatient, outpatient and day patient attendances for both acute and mental health specialty services. Providing health records to external health boards, hospitals and other non NHS agencies. Providing support to clinical outpatient reception areas. 2. The management of the release of clinical information relating to patients: Responding to Subject Access Requests in accordance with the provisions of the Data Protection Act/ Access to Health Records Act/Freedom of Information Act. Releasing where appropriate information to courts, police, procurators fiscal, insurance companies, criminal injuries compensation authorities and mental welfare commission etc. 3. The provision of Scottish Morbidity Records (SMR schemes) to ISD/central Scottish Government on behalf of NHS Tayside: Collating and coding patient clinical/demographic information for the creation of SMR returns to provide national statistical information/support local planning of health services. Ensuring all SMR returns i.e. SMR00 (out patient attendances). 01 (acute in-patient/day case admissions), 02 (Obstetric in patient/day case admissions) and 04 (Psychiatric in patient/day case admissions) are submitted in a valid state and processed on time in line with the guidelines laid down by ISD. 4. The creation/provision/storage/disposal of health records Ensuring all patients are registered with a national unique CHI number for record linkage. Processing all referral requests for new patients requiring specialist services within Tayside and where appropriate booking the first appointment in line with clinical instructions i.e. screening process. Managing the patient administration systems TOPAS and PCSMR and supporting/training authorised users. Creating health records for new patients. Providing records to support clinical care i.e. out patient attendances/admissions. Ensuring the safe storage of records in the designated libraries throughout NHS Tayside. Selecting for destruction (in accordance with local/national retention policies) those records that have reached or exceeded their minimum retention period and arrange safe disposal via authorised contractors. Maintaining records inventories. docs_ doc Page 43 of 85

44 SECTION 4 Appendix 2 NHS TAYSIDE : HEALTH RECORDS SERVICE Management Structure Access General Manager/ Associate Medical Director Access Service Manager Senior Health Records Manager NHS Tayside Health Records Based at Ninewells Hospital Data Quality Manager Health Records Manager Health Records Manager Health Records Manager Referral Governance Facilitator Perth Dundee Angus Perth Royal Infirmary Murray Royal Infirmary Ninewells Carseview Stracathro Stracathro/ Sunnyside docs_ doc Page 44 of 85

45 SECTION 4 Appendix 3 NHS TAYSIDE : HEALTH RECORDS SERVICE Training and Induction All staff employed by the NHS Tayside Health Board including volunteers and contractors are given training on their personal responsibilities for health records keeping. This includes the creation, use, storage, security and confidentiality of health records. Appropriate training will be provided for all users of the health records systems to meet local and national standards. All new employees to the organisation will be given basic training as part of the organisation's induction process. Additional training in the specifics of health records management will be provided where appropriate and identified through the staff personal development planning process. Training is tailored to individuals and specific staff groups covering key functions including the following:- all current relevant legislation and NHS standards; all current relevant organisation policies and procedures; Caldicott requirements; Patient confidentiality and the security of records, whether paper or electronic; Data Protection Act 1998; Access to Health Records Act 1990; Scottish Government Records Management NHS Code of Practice (Scotland); secure destruction of confidential waste; individuals rights to access information (Data Protection Act 1998/Mental Health (Scotland) Act 2003); NHS Scotland Code of Practice on Confidentiality; Patient Records and Information Management Accreditation Programme (PRIMAP). Records inventory requirements Health records practitioners and personnel are pivotal to the management of health records systems and should receive customised training in health records practice. The standard operating procedures manual is a key management tool and forms the basis for all health record system specific training. NHS Tayside supports health records service staff members in acquiring recognised professional qualifications in Health Records management provided by the Institute of Health Records and Information Management (I.H.R.I.M.). Training Plan Key training in the implementation of the policy will be provided through a train the trainer approach by Health Records Service Managers. Individual services would develop cascade training supporter by Health Records. The use of Learn Pro e-training will be developed to support implementation and training which would become an integral part of relevant staff groups e-ksf. docs_ doc Page 45 of 85

46 SECTION 4 Appendix 4 HEALTH RECORDS MANAGEMENT HIGH LEVEL IMPROVEMENT PLAN Strategic Aim/ Improvement Action NHS Tayside has an approved organisation-wide Strategy for Health Records Management in NHS Tayside approved by the Board, or its delegated Committee. NHS Tayside has an approved Policy for Management of Health Records in NHS Tayside. There is an agreed consultation process and implementation plan for The Health Records Management Policy and an audit and review of policy incorporated in local implementation plan. NHS Tayside has an approved Improvement Plan to support the implementation of the Strategy for Health Records in NHS Tayside. Form an Area Health Records Committee with clear remit and objectives. NHS Tayside has strategic reporting arrangements for Health Records issues within NHS Tayside. Develop marketing material outlining the role of the Health Records Service across NHS Tayside and circulate widely. Actively promote the role and development of the Health Records Service across NHS Tayside. Reference to Relevant National Standards CEL 31 (2010) CEL 31 (2010) PRIMAP 1.1 CEL 31 (2010) CEL 31 (2010) PRIMAP CEL 31 (2010) PRIMAP 8.1 PRIMAP 8.2 Progress Strategy to be incorporated in policy document. Policy to be submitted to EMT and Improvement and Quality Committee. Improvement Plan incorporated in Health Records Management Policy. See paragraph 6.4 of Health Record Policy. All Health Records issues to be submitted through the IG Committee structure. Ensure Health Records Committee is established and has multi-disciplinary representation. Develop close working relationships with Clinicians, Managers and all other appropriate staff in the management of Health Records across NHS Tayside. Implement an annual rolling programme of inspection of all Heath Records storage areas in Tayside. Develop and manage an annual Risk Register for Health Records issues across NHS Tayside. All Health Records staff and staff in other areas are aware and receive training and guidance in the implementation of Service Operating Procedures. Implement a programme of annual retention, destruction and archiving of patient health records in accordance with the agreed retention schedules. The programme to make sure that confidentiality is maintained. Actively contribute to the development of the single electronic patient record (clinical portal). Actively participate in the roll-out and system support of TOPAS across NHS Tayside. Participate in the roll-out of the electronic case record tracking/management system. Review potential to employ technology to address storage issues. CEL 31 (2010) PRIMAP 4.9 See Appendix 3 of Health Records Policy and Service Operating Procedure 1. See Service Operating Procedure 8. docs_ doc Page 46 of 85

47 SECTION 4 Appendix 5 Health Records Service Operating Procedures Procedure Operating Procedure Name Number 1. Retention Destruction and Archiving of Health Records 2. Confidentiality/Security and the Release and Management of Information 3. Security of Health Records Storage Areas 4. Transportation of Health Records Within and Out with Organisation Boundaries 5. Electronic Transmission of Patient Identifiable Data 6. Temporary and Duplicate Health Records 7. Medical Records Filing Systems 8. Case Record Tracking /Tracering 9. Missing Case Records 10. Alerting Clinical Risks and Recording within Health Records 11. Splitting of Voluminous Health Record Folders 12. Return of Discharged Patient Records to Health Records Library 13. Searching and Updating Patient Demographic Data in the Master Patient Index 14. Handling of Subject Access Requests 15. Filing of Loose Documentation 16. Registration of Patient Referrals on Patient Administration System 17. Standardisation of Clinic Master/Clinic Profile Naming 18. Booking of Ambulance Transport docs_ doc Page 47 of 85

48 NHS Tayside Health Records Service Operating Procedure (see Section 3) Number 1: Retention, Destruction and Archiving of Health Records 1. Opening Statement The Data Protection Act 1998 sets out a series of standards which NHS Boards and other NHS bodies must meet in order to comply with the law. One of these is that they must comply with the Fifth Data Protection Principle which is that "Personal Data processed for any purposes shall not be kept for longer than is necessary for that purpose or those purposes". 2. Retention Periods NHS Tayside has adopted the minimum retention periods as set out in Section 3, which is derived from Annex D of the Scottish Government Records Management: NHS Code of Practice (Scotland) 2010 see pages 19 and 20 for local retention policy for main health record types. This document provides the retention schedule of standard minimum retention periods along with a further breakdown of information and advice about the retention of all personal health records commonly found within NHS organisation including : personal health records (electronic or paper-based, and concerning all specialties, including GP medical records); records of private patients seen on NHS premises; Accident and Emergency, birth and all other registers; theatre, minor operations and other related registers; x-ray and imaging reports, output and images; photographs, slides and other images; microform ( i.e. microfiche/ microfilm); audio and video tapes, cassettes, CDROMS etc; s; records held on computer and scanned documents. 3. Exceptions No surviving health records dated 1948 or earlier should be destroyed. Local exceptions as detailed on Page 20 (Section 3) 4. Disposal and Destruction of Personal Health Records Operational Managers are responsible for making sure all records are periodically and routinely reviewed to determine what can be disposed of in keeping with NHS Tayside policy. At the end of the minimum retention period one or more of the following listed actions will apply:- 1. Review records may need to be kept for longer than the minimum retention period due to ongoing administrative and or clinical need. If it is decided that the records should be retained for a period longer than the minimum, NHS Tayside retention schedules will be amended accordingly and a further review date set. Otherwise one of the following will apply:- 2. Transfer - to or consult with the NHS Tayside approved archivist -Archivist, Dundee University, if the records have no ongoing administrative value but have long term historical research value, OR docs_ doc Page 48 of 85

49 3. Destroy records selected for destruction are catalogued by destruction date for future reference. Confidential destruction/disposal of health records is carried out in accordance with NHS Tayside s policy and procedures relating to Confidential Waste. Reference NHSMEL (2000)17: Data Protection Act The Management Retention and Disposal of Personal Health Records ANNEX - D - Records Management: Code of Practice (Scotland) 2010 Links Section 3 Health Records Management Policy Service Operating Procedure 2: Confidentiality/Security and PRIMAP Standard 4 (point 4.9) - The Release and Management of Information docs_ doc Page 49 of 85

50 NHS Tayside Health Records Service Operating Procedure Number 2: 1. Opening Statement Confidentiality/Security and the Release and Management of Information Everyone working in the NHS has a legal obligation to keep all patient related information confidential. Security and Confidentiality of data applies not only to manual health records but also computer systems both administrative and clinical, e.g. PAS, Laboratory, Radiology systems etc. 2. Your Responsibility Staff should read and be aware of the content of the NHS Code of Practice on protecting patient confidentiality (yellow booklet). This may be provided with letter of appointment but a supply will be available in the local Medical Records Department. It is also available via the Information Governance website on NHS Tayside Staffnet. All staff must sign a confidentiality statement on commencement of duty (there is a clause in all staff contracts of employment). Any breach of confidentiality will attract disciplinary action, which may lead to dismissal. 3. What Constitutes Confidential Data All information held about a patient is regarded as confidential. This includes: demographic/administrative data as well as clinical data, e.g. name, address, postcode, telephone number, clinic attended, appointment details. Medical records staff should only access the information they need to carry out their duties. Staff should take care when discussing their work with colleagues e.g. not gossiping and taking care not to be overheard in public places. 4. Security All Medical Records libraries in NHS Tayside can only be accessed by staff with the proper access credentials i.e. ID badge which operates the lock mechanism. All visitors with business to carry out in the library e.g. secretaries filing loose documentation in case records, doctors/medical students/other health professionals carrying out audit/research must report to the reception point and sign-in. The off-site storage facility at Claverhouse can only be accessed by prior arrangement with Medical Records Managers. 5. Security of Computerised Data Medical Records staff will have an approved level of access to computer systems to enable them to carry out their duties. Access to systems is by LDAP/password/user name and the password should only be known to the user. Passwords must never be given to or shared with other members of staff. Staff are responsible for keeping their LDAP/passwords safe/secret and up to date. Staff must ensure they log out of systems when not in use. Most computer systems have in-built audit trails so it is known which records have been accessed and by whom. This emphasises the need to keep passwords secret at all times. On termination of employment the IT Department will ensure all access rights to systems is removed. 6. Staff Members with a Legitimate Right to Access Confidential Data In order to carry out their duties many health service staff require day to day access to patient's medical records or computerised data. Those staff with legitimate access include Medical, docs_ doc Page 50 of 85

51 Nursing, Research, Health Records, Medico/legal, clinical effectiveness, and Allied Health Care Professionals etc. 7. Data Protection Act/Access to Health Records Act NHS Tayside will comply with the principles of the Data Protection Act 1998 with regard to the handling of subject access requests. The Access to Health Records Act 1990 will be complied with in regard to rights of access in relation to deceased patients only. For full information on types of requests, timescales and costs see operating procedure Information Sharing This process usually requires the consent of the patient. This may be implicit i.e., implied when the patient seeks medical care or explicit i.e., the patient makes an informed decision to consent to the release/sharing of their data. Examples of information which may be divulged under statutory obligation include: Notification of Infectious Diseases Notification under child protection arrangements Notification of Births/Deaths Reference Data Protection Act 1998 Access to Health Records Act 1990 Computer Misuse Act 1990 Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating Procedure number 3: Security of Health Records Storage Areas Service Operating Procedure number 14: Handling of Subject Access Requests Caldicott Principles "Protecting Personal Health Information" - Information Guide for Patients (Produced by ISD) "Confidentiality - It's Your Right" (Produced by NHS Scotland) "Confidentiality - A guide for young people under 16" (Produced by NHS Scotland) "How to see Your Health Records" (produced by NHS Scotland) Policy: Local IT Security Health Rights Information Scotland (HRIS) PRIMAP Standard 4 (point 4.17) docs_ doc Page 51 of 85

52 NHS Tayside Health Records Service Operating Procedure Number 3: Security of Health Records Storage Areas 1. Opening Statement Storage has a huge impact on the effectiveness of the service provided. Areas must be secure to protect records against loss, damage or access by unauthorised persons. 2. Health Records Libraries Main record storage areas should be only accessible via a swipe card system or keypad locks. Other storage areas may be secured under lock and key. 3. Peripheral Office Accommodation and Storage Areas Offices and other areas used to store records should be secured using lock and key, swipe card or keypad entry. Access should be available out of hours by authorised persons only. Keys for these areas should either be locally held copies (e.g. Medical Records Department) or be held centrally and be signed for each time. A records inventory should be implemented for storage of records within these areas as an up-to-date health records inventory will be maintained by the Senior Health Records Manager. 4. Off-site Storage These areas should have controlled entry ensuring that persons requiring access have to sign in and produce ID before entering. If this control is not available then lock and key should be used with staff having to sign for keys. A records inventory should be implemented for storage of records within these areas as an up-to-date health records inventory will be maintained by the Senior Health Records Manager. 5. Electronic Storage Access to document store is by LDAP. Control of LDAP register is with the system administration. 6. Access All Medical Records staff Medical secretarial staff require to sign in/out of restricted areas. Portering/mail room staff Estates personnel Domestic staff IT staff on business required to sign in/out of restricted areas. Clinical staff with valid reasons for access - required to sign in/out of restricted areas. Caldicott approval needed for research purposes. Reference Records Management: NHS Code of Practice (Scotland) Links Service Operating Procedure number 2: Confidentiality/Security and the Release and Management of Information Local Moving and Handling, Health & Safety, Security and Lone Working policies PRIMAP Standard 4 (point 4.21) docs_ doc Page 52 of 85

53 NHS Tayside Health Records Service Operating Procedure Number 4: Transportation of Health Records within and outwith Organisation Boundaries 1. Opening Statement Patients' Health Records contain personal and sensitive information and are highly confidential documents. Care must be taken when transporting them within or outwith NHS Tayside. NHS Tayside Health Records Service have the responsibility to manage the records in their possession and to deliver the records to the location requested by practitioners. When the records are delivered to the practitioner it is their responsibility to maintain them. Should the practitioner decide that the records may have to be transferred to another location or back to the records library, then it is their responsibility to arrange that, including transport and any associated cost if internal mail is not considered to be appropriate, this should be on the rare exception. Once the practitioner has the records it is not the Health Records Service function to provide a mailing service for them or pay for such a service. 2. Transportation of Health Records within NHS Tayside Health records must be securely packed for internal transfer or for carriage by internal transport service to other hospitals, clinics or offices in NHS Tayside. A number of handling and transportation packaging methods may be used for the secure transfer of physical health records within NHS Tayside boundaries and to partner organisations. These include: purpose designed plastic boxes with seals; brown paper envelopes; brown paper and string; non-tearable textured envelopes; single record envopak carriers with seals; multiple record envopak carriers with seals; lockable pilot bags. The name and the exact location for delivery should be clearly marked on the envelope / box. All internal mail containing health records or patient information should be marked Medical In Confidence Transit envelopes must not be used for internal transporting of health records and information. Bundles of Health Records must be securely tied in a manner which prevents patient details being visible. Health records must be transferred using appropriate trolleys or cages and never be deposited and left unattended in areas that are not secure e.g. entrances, corridors, stairways or in vehicles where the package is visible or the vehicle unlocked. 3. Transportation of Original or Copy Health Records to Hospitals or Authorised Agencies outwith the Internal Mail Delivery Service Health Records for transfer by post must be secured in stout envelopes for transit by a safe collection and transport service. The transit of Confidential material must be secured in an envopak or in a double envelope. The inner envelope should indicate prominently Medical In Confidence, the name and address of the recipient and the name and address of the sender. The outer envelope must indicate only the name and address of the recipient. Both envelopes should be sealed. docs_ doc Page 53 of 85

54 Transit envelopes must not be used for external transporting of health records and information. If the Royal Mail is used then the Recorded Delivery Service must be employed. If any other carrier service is used then a receipt of the transit must be obtained. 4. Lifting and Handling of Health Records See local Moving & Handling and Health & Safety policies. 5. Staff Transportation of Health Records Staff awareness of procedures for safe and confidential physical transportation of health records throughout the organisation. Reference Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating Procedure 2: Confidentiality/Security and the Release and Management of Information Service Operating Procedure 8: Case Record Tracking/Tracering Local Moving & Handling and Health & Safety policies PRIMAP Standard 4 (point 4.28) docs_ doc Page 54 of 85

55 NHS Tayside Health Records Service Operating Procedure Number 5: Electronic Transmission of Patient Identifiable Data 1. Opening Statement The procedure below conforms with the guidance contained within NHSMEL (1997) 45 "Guidance on the use of facsimile transmissions for the transfer of personal health information" and local policy on ing patient identifiable data. For the safe transmission of electronic patient data no information identifying the patient should be faxed. 2. Safe Haven All medical records locations in NHS Tayside have a fax machine located within a safe environment i.e. within a protected departmental area where confidentiality can be guaranteed. All operational fax machines must display the correct time and date at all times to ensure all received faxes are accurately time/date stamped. NHS Tayside safe haven fax numbers: Ninewells Hospital Perth Royal Infirmary Stracathro Hospital Carseview Centre Murray Royal Hospital Claverhouse AHP Directorate Office DHCCC Maryfield House Centre for Brain Injury Rehab Roxburgh House Transmitting Fax Messages/Removal of Demographic Details The use of fax for sending patient identifiable data should only be done when information is required urgently. The following steps must be adhered to at all times to ensure fax messages reach the intended recipient: all fax messages must be accompanied by a cover sheet which incorporates the confidentiality statement. when sending a fax containing patient information, photocopy the original paperwork ensuring that all demographic information identifying the patient has been blanked out e.g. name, address. telephone the intended recipient stating that a fax message is about to be sent and at this time check the recipient's fax number and that their fax machine is in a secure location. request that the recipient telephones to confirm safe receipt if certain fax numbers are commonly used then these should be dialled in and saved in the fax machine to prevent dialling errors 4. Receipt of faxes When requesting information from another source ensure that the safe haven fax number has been given and recorded correctly by the sender. Telephone the sender to confirm safe receipt. All received faxes must display the correct time/date stamp. docs_ doc Page 55 of 85

56 5. Receipt of Electronic Referrals All electronic referrals in NHS Tayside are managed within the Referral Management System (RMS) and the SCI store equivalent which are integral to the Board's ehealth strategy. Both systems are accredited to the highest level for security and confidentiality and are now fast becoming the chosen way for General Medical Practitioners and other health professionals to refer patients for hospital care. Electronic referrals are received via the RMS within a safe location in all medical records departments in NHS Tayside on a daily basis. They are printed off and processed by medical records staff as part of their routine work. Some electronic referrals will have been pre-vetted by a hospital clinician and these can proceed and be dealt with as per the clinician's instructions. On the other hand some referrals will not have been vetted and these referrals must be collated and sent to the appropriate clinician/department for vetting without delay. 6. Use of to Transmit Patient Identifiable Data Some medical records staff may from time to time in the course of their work send patient identifiable data by . The system in use in NHS Tayside is NHSmail which meets all recommendations on security and confidentiality. However NHSmail does not protect information before it has been sent or after it has been received therefore staff using to send sensitive information must ensure that the information is protected on their own system and that of the recipient. Some staff from time to time may work from home. Staff who fall into this category must ensure that their home 'workplace' is as secure as their normal workplace in terms of security and confidentiality. Reference Records Management: NHS Code of Practice (Scotland) 2010 NHSMEL (1997)45 "Guidance on the use of facsimile transmissions for the transfer of personal health information" Links Service Operating Procedure 1: Confidentiality/Security and the Release and Management of Information Service Operating Procedure 16: Registration of Patient Referrals on Patient Administration System PRIMAP standard 4 (point 4.31) NHS Tayside e-health Strategy NHS Tayside Referral Management System NHS Tayside-Use of and Network Services Policy NHS Tayside Use of Portable Computers and Removable Data Policy docs_ doc Page 56 of 85

57 NHS Tayside Health Records Service Operating Procedure Number 6: Temporary and Duplicate Health Records 1. Opening Statement A temporary case record folder may only be issued on the instruction of a member of the management team when she/he is satisfied that an exhaustive search has been carried out and original case record cannot be found. When duplicate registrations are identified action must be taken to amalgamate both physical case record and computerised system. 2. Procedure for Issuing Temporary Case record Folder Senior Medical Records staff (team leader) can authorise the creation of a duplicate or temporary case note folder. This should only be done after an exhaustive search for the original records. All relevant correspondence should be sourced from, electronic systems, e.g. Central Vision, Document Store, secretarial staff and general practitioners. The new folder should clearly be marked that this is not the original but a temporary/duplicate. 3. Amalgamation of Documentation When original case note folder is located then this should be checked with the temporary to ensure that the original is complete. Duplicate information should be destroyed confidentially. 4. Tracking of Temporary Case records Temporary case notes should be clearly marked as such using the case note status in electronic tracking system. This should be removed if original found. 5. Amalgamation of Duplicate Registrations/Case records Where duplicate registrations occur, this is usually due to erroneous new registrations or if the patient has two registrations covering different board areas. The correct number should be ascertained completing Duplicate Registration form or following advice from CHI Administrator. When a duplicate registration, electronic systems should be updated by merging the wrong number with the correct number. Case notes should be amended to reflect the current number and any incorrect labels destroyed Reference Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating Procedure number 2: Confidentiality/Security and the Release of Management Information Service Operating Procedure number 8: Case Record Tracking/Tracering Service Operating Procedure number 9: Missing Case Records PRIMAP Standard 4 (point 4.38) docs_ doc Page 57 of 85

58 NHS Tayside Health Records Service Operating Procedure Number 7: Medical Records Filing Systems 1. Opening Statement The prime purpose of a Health Records Department is to bring together 3 key players, the patient, the doctor/healthcare professional and the case record i.e., have the right case records in the right place at the right time. Whichever filing system is used, it is imperative that case records are filed accurately as a great deal of time can be wasted searching for mis-filed records. Failure to produce the case record can result in: past medical history being unavailable; refusal/delay by Consultant to see patient; cancellation of procedure; distress to patient/relative; increase in clinical risk. 2. Filing System NHS Tayside complies with national requirements by using the unique patient identifier i.e. CHI (Community Health Index) number to register health records and manage patient records for storage and retrieval purposes. The CHI number is a unique numeric identifier, allocated to each patient on first registration with the system. It is a 10 character code consisting of the 6 digit date of birth (DD/MM/YY), 2 digits, a 9 th digit, which is always even for females and odd for males, and an arithmetical check digit. CHI contains details of all Scottish residents registered with a general practitioner. It is a key component in the implementation of Electronic Patient Record. Filing systems for all record collections including acute medical records and mental health records are catalogued sequentially in their respective libraries by using the day, then the month, then the year as subdivisions with further identification provided by the unique four digit number of the CHI. This terminal-digit filing system is used to make numeric filing and retrieval more efficient and accurate. 3. Case records Storage Systems The main health record libraries within NHS Tayside for acute medical record services are located at: Ninewells, Perth Royal Infirmary and Stracathro Hospital; Inactive records at Perth Royal Infirmary are stored on microfiche as a secondary storage medium; The main health record libraries within NHS Tayside for mental health record services are located at; Carseview Centre, Murray Royal Hospital and Stracathro Hospital; Mental health records for children and adolescent patients are held within the library at Centre for Child Health in Dundee; Tayside Psychological Therapy Services retain patient records for all of Tayside within their library at 7 Dudhope Terrace, Dundee, with the exception of Murray Royal Hospital who retain their own patient records. Inactive patient records and deceased patient records for both the acute and mental health services are stored in a secondary off-site storage facility at Claverhouse in Dundee. docs_ doc Page 58 of 85

59 4. Identification/Retrieval of Patient Records All requests to access a patient health record require the identification of the individual patient to be validated using the electronic CHI system. Definition of Terms & Acronyms Health Record the health record is a single record with a unique identifier, which is a composite of all data on a given patient. It contains information relating to the physical or mental health of an individual who can be identified from that information and which has been recorded by, or on behalf of, a health professional, in connection with the care of that individual. This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the on-going care of the patient to whom it refers. Reference Standard BS.5454:2000 Standard ISO Links Service Operating Procedure 1: Retention, Disposal and Archiving of Health Records Service Operating Procedure 2: Confidentiality/Security and the Release and Management of Information Service Operating Procedure 3: Security of Health Records Storage Areas Service Operating Procedure 4: Transportation of Health Records (Local Moving & Handling policy) PRIMAP Standard 2 (point 2.27) PRIMAP Standard 4 (point 4.21) docs_ doc Page 59 of 85

60 NHS Tayside Health Records Service Operating Procedure Number 8: Case record Tracking/Tracering 1. Opening Statement When case records are removed from the filing system or given from one person to another the tracer card (where still in use) or the computerised tracking system (TOPAS) is updated with the case records new location e.g. clinic ward of admission, clinician's office etc. Failure to update the tracer card or tracking system as case records are removed from file or change location may result in case records not being available when required. 2. General Principle When a case record is required to be removed from any records library e.g. admission/out patient attendance/other reason the case notes new location must be entered onto the tracer card or in the tracking system by medical records staff. The following information must be recorded: date/clinic/ or ward or office etc. When the notes are received at the new location the recipient e.g. out patient receptionist/medical secretary/ward clerk is responsible for recording receipt of the case records either by completing an entry in a register or confirming receipt in the tracking system. If the records are subsequently passed to a new location then the new location must be passed to the medical records department so the tracer card may be updated or the records tracking system is updated with the new location by the sender. 3. Process for Confirming Case records Back into File When case notes are to be returned to the medical records library the sender must record this in their register or in the tracking system. On receipt at the records library medical records staff will pre sort the case notes into order i.e. hospital/current/secondary/deceased. The case records will then be passed to the correct library for re-filing and then married with the tracer card or placed in the correct place on the shelf in the correct store. The tracking system will also be updated with the records library location. 4. Computer System Downtime Reference In the event of computer system downtime and the tracking system cannot be updated, staff in all areas must compile a list of case note movements utilising the bar code/patient labels in the case records recording the date/time and destination of case records. When the system has been reinstated the tracking system must be updated immediately by all senders/recipients of case records. When the system has been reinstated the tracking system must be updated immediately by all senders/recipients of case records case records. When the system has been reinstated the tracking system must be updated immediately by all senders/recipients of case records. Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating Policy 4: Transportation of Health Records within and outwith Organisation Boundaries Service Operating Policy 7: Medical Records Filing Systems PRIMAP Standards 2 (point 2.28) and 3 (point 3.11) TOPAS Case Note Tracking System User Guide docs_ doc Page 60 of 85

61 NHS Tayside Health Records Service Operating Procedure Number 9: Missing Case Records 1. Opening Statement Health Records staff are responsible for ensuring that all patients' case records are available for any attendance or admission the patient may have at hospital. In addition to this, case records require to be obtained timeously for a number of administrative processes. 2. Chart Tracking History If case notes are not in file then checks should be instigated to check the previous history of case note movements and last few locations. The patient s GP should be contacted to ascertain if the patient has been to other, nondocumented areas. 3. Procedure for Obtaining Missing Case records If the case notes are missing but have been returned to their home location then the following step by step guide should be used: Check the shelf where the records belongs (i.e. day/month of birth, 01/01) Check shelves immediately above and below Check next/previous day of birth Check pre-sort area, awaiting filing, duplicate volumes section, deceased filing, maternity records Other libraries in area. 4. Escalating Problem if Case Records Cannot be Found Senior Medical Records staff (team leader) can authorise the creation of a duplicate or temporary case note folder. This should only be done after an exhaustive search for the original records. 5. Case Record Located When original case note folder is located then this should be checked with the temporary to ensure that the original is complete. Duplicate information should be destroyed confidentially. Reference Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating procedure number 6: Temporary and Duplicate Case Records docs_ doc Page 61 of 85

62 NHS Tayside Health Records Service Operating Procedure Number 10: Highlighting Clinical Alerts/Risks and Recording within Case Records 1. Opening Statement To help ensure that patient care is delivered as safely as possible all case note folders shall have an appropriate space for the recording of clinical alerts/risks. These can be defined as e.g.:- Allergies Risk factors when dealing with an individual patient 2. Procedure The front cover of the case note folder should be appropriately highlighted with e.g., a tick in the allergy box or a sticker to indicate that an alert/risk exists. The full details of the alert/risk are recorded on the inside cover or in the appropriate space on the Abstract Sheet. All entries must be dated and signed by the health professional noting the alert/risk. Reference Records Management: Code of Practice (Scotland) 2010 Links PRIMAP standard 3 (point 3.4) docs_ doc Page 62 of 85

63 NHS Tayside Health Records Service Operating Procedure Number 11: Splitting of Voluminous Health Record Folders 1. Opening Statement When the documentation relating to a patient can no longer be securely filed in one volume, a second volume is created to hold the overflow. Some patients may require a third or fourth volume in order to keep the health record manageable. 2. Numbering NHS Tayside records libraries split health records with large volumes of documents by creating a second and often further volumes of records. Historically, these additional volumes have been subject to different numbering procedures relating to the different locality health records libraries. For example, new folders created as a result of splitting health records may be marked as Volume 2, or File B, or Folder 1 of 2. Consistency within each library ensures best practice. 3. Procedure for Splitting Health records Whilst local practice may vary (see paragraph 4 below) the following essential aspects of splitting health records will be adhered to:- It is essential that health records are split either at the end of an episode of care or at a convenient point in time e.g., end of a Month/Year; Health records requiring second volumes must be discussed with clinician to ensure any key documentation identified is copied to the new volume; Second volume will be dated with creation date visible on front cover and noted on internal abstract sheet; Closure date of first volume will be recorded and visible on front cover and noted on internal abstract sheet; A tracer card is provided for each volume and dated appropriately with the creation date; Earlier volumes should be held in a designated secondary storage area in each library to prevent their inadvertent use; When releasing records with more than one volume, the clinician will be made aware that earlier volumes are in existence should they be required; The contents of each volume will be listed; Retention periods will be applied to all volumes of health records. 4. Local Medical Record Library Practice Acute Hospital Case Notes Ninewells Hospital 1. The new volume will hold the current specialty in which the patient is being seen e.g. if a patient was referred to an ENT clinic and the record required to be split the ENT divider and documentation would be put into a new volume at the pre registration process with the previous records remaining in the old volume. 2. The old volume is marked as Volume I of 2 and the new volume marked as 2 of medical records staff may go down to wards to split folders with the current specialty being filed in the new volume 4. The case record marked as e.g. volume 2 of 2 hold the most up to date information. Perth Royal Infirmary 1. The new volume will be marked as Folder 1 of 2 and the old one as 2 of 2. Folder 1 holds the most up to date information. 2. The new folder will hold the most up to date correspondence e.g. from 2008 onwards. docs_ doc Page 63 of 85

64 The old folder will be marked as holding older correspondence e.g All specialty dividers, history and current mount sheets will be transferred to the new folder. 4. The most recent nursing notes will be placed in the back pocket of the new volume. 5. The case record marked folder 1 holds the most up to date information. Stracathro Hospital 1. Case records are checked before leaving an on return the records library. 2. A new volume will be created, if required, containing the most up to date information. 3. The case record marked as e.g. volume 2 of 2 holds the most current information. Mental Health Case Records 1. Case records are sent to the medical records department when another volume is required. 2. The case record is then split at an appropriate place e.g. before or after an admission or in the case of a long term patient, at the end of a year. 3. Record the date closed on the folder and mark it as volume 1 4. Generate a new folder and tracer card, mark the folder with the date it was opened and also mark as volume Tracer cards will also be marked with the correct volume number and the dates volumes were opened/closed. 6. The case record folder with the highest number holds the most up to date information. Angus mental health records use lettering e.g. A, B, C with volume C holding the most up to date information. Reference Records Management: NHS Code of Practice (Scotland) 2010 Links: Service Operating Procedure 1: Retention, Destruction and Archiving of Health Records Service Operating Procedure 7: Medical Records Filing Systems Service Operating Procedure 8: Health record Tracking/Tracering PRIMAP Standard 3 (point 3.10) docs_ doc Page 64 of 85

65 NHS Tayside Health Records Service Operating Procedure Number 12: Return of Discharged Patient Records to Health Records Library 1. Opening Statement All records in Tayside are now electronically tracked using the Patient Administration System. Records should be automatically returned to the relevant Records Library at the earliest opportunity. 2. Procedure for Receiving Records Being Returned to File All records being returned to file should be scanned back to file (home location) using the Case note Tracking module of the PAS upon receipt of the records. This may be done individually or as part of as larger batch of records using the batch slip which should be attached. 3. Reserved Records Case notes received back to the library which have been reserved on the Tracking System or have control cards in place should be forwarded on to the requested destination and tracked accordingly on the system. 4. Deceased Records Records of deceased patients should be clearly marked on the external cover of the record. When these are returned to the library, the records should be recorded to the deceased file. Care should be taken that the date of death is also recorded on the system. 5. Records Required by Clinical Coding Records required to complete SMR episodes that have not been through the coding process should be clearly marked. Such records should ideally reach the library via Clinical Coding but any record marked such should be sent immediately for coding. Clinical Coding staff should then log the records and dispatch them to library once finished with. 6. Completeness of Records Any record being returned to the Records Library should be in a condition that no work is required by Records staff to enable the record to be in a fit state for the next user. Users of the record should ensure that all correspondence, filing, etc. is in the correct place before returning the record. Reference Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating Procedure number 4: Transportation of Health Records Within and Outwith Organisation Boundaries Service Operating Procedure number 8: Case Record Tracking/Tracering PRIMAP Standard 3 (point 3.11) docs_ doc Page 65 of 85

66 NHS Tayside Health Records Service Operating Procedure Number 13: Searching and Updating Patient Demographic Data in the Master Patient Index (MPI) 1. Opening Statement The Master Patient Index is an alphabetical key to records which are filed numerically. It allows patient search, amendment to patient demographics and registration of new patients creating a departmental patient identification number which is linked to the Community Health Index number as the unique patient identifier. It can be kept on a computerised patient administration system (PAS) or on a manual card system. The electronic system with an MPI currently in use within NHS Tayside is known as TOPAS. 2. Information Held on Master Patient Index The following demographic information is held on the MPI: CHI number date of birth name address and postcode temporary address and postcode home, work and mobile telephone numbers health board of residence general medical practitioner/general dental practitioner next of kin ethnicity religion date and place of death periods of unavailability for hospital treatment demographic history 3. Search and Registration Techniques To help trace previously registered patients in TOPAS the following search fields are available: full patient demographics surname forename date of birth name sex CHI number A search can be completed to trace the correct patient by using a single field or combination of fields, e.g. date of birth or name and date of birth. Authorised medical records staff have access to CHI24 (National CHI) which allows the registration of new patients not previously registered in Scotland. These patients are allocated their CHI number and their demographic information is subsequently available to be downloaded to TOPAS via the A-CHI SCI search feature. Also for patients already registered on the national CHI a search can be completed in A-CHI/SCI store for patients not previously registered in Tayside. If the correct patient is traced then the patient's demographic information can be downloaded to TOPAS via the A-CHI SCI search feature. docs_ doc Page 66 of 85

67 4. Maintenance of Master Patient Index All patient demographic information is recorded, updated and saved in the MPI. The recording/updating of this information is the responsibility of the medical records department and can be done either on the receipt of an out patient referral letter or on the admission of a patient to hospital or at out patient reception desk. The recording of patients deaths in the MPI is done by way of one of the following: recorded by ward staff in bed management system. notification forms sent by wards/departments to medical records department or by message left on out of hours answer phone.. notification received by medical records department from Registrar General's Office or from the patient's general medical practitioner. 5. Unknown Patients If a patient attends the A/E department and is unable to provide their demographic information he/she is added to the A/E electronic system (Symphony) as 'unknown male or female'. Once demographic information is established Symphony and if appropriate, PAS/MPI is updated with the demographic information. If a patient is admitted directly to a ward and is unable to provide demographic information, the ward must inform the medical records department of the patient's arrival. The admissions register held within medical records is updated with an entry 'unknown male/female, time and ward'. Once the demographic information has been established the ward shall inform medical records who will register the patient in PAS/MPI and provide the relevant case records. 6. Data Quality The following fields are mandatory within the MPI: CHI number date of birth name address health board general practitioner demographic history In the event of a duplicate patient registration being notified to the medical records department or discovered during work processes the MPI records will be merged within PAS with the earlier registration (CHI number) being adopted as the correct number for use. If there are two sets of case records for the patient then these shall also be merged using the correct CHI number. Reference Records Management: NHS Code of Practice (Scotland) 2010 Links Service Operating Procedure number 6: Temporary and Duplicate Health Records PRIMAP standard 4 (points 4.10 and 4.12 docs_ doc Page 67 of 85

68 NHS TAYSIDE HEALTH RECORDS SERVICE OPERATING PROCEDURE NUMBER 14: HANDLING OF SUBJECT ACCESS REQUESTS Opening Statement NHS Tayside will comply with the principles of the Data Protection Act 1998 with regard to the handling of subject access requests. The Access to Health Care Records Act 1990 will be complied with in regard to rights of access in relation to deceased patients only. A Background to the Acts The Acts give patients or their representatives the right of access, subject to certain exemptions [see D and E below], to most health records containing information about themselves, relatives, etc. Access can be restricted in specified circumstances and then only to the sensitive part of the record. B Right of Access The following people have right of access:- The patient. A person authorised in writing, to apply on behalf of the patient e.g. relative, solicitor, insurance company. Where the patient is a pupil, the parent or guardian. Any person appointed by the court to manage the affairs of a patient who is deemed to be incapable. Where a patient has died, the patient s representative, or any person having a legal claim arising from the death. C Application If a patient asked to see their Record during a consultation or treatment, and this is practical, the Clinician should co-operate. This may include arranging a mutually suitable time at a later date. If it is not possible to agree at that time, or if a patient decides later to request access, the application should be made in writing. D Whole or Partial Exemptions Cases where access may be wholly excluded: Access shall not be given unless the holder of the record is satisfied that the patient is capable of understanding the nature of the application. Where the applicant is the parent or guardian of the patient who is a pupil, access should not be given unless the holder of the record is satisfied that the patient has consented to application or that the patient is capable of understanding the nature of the application and the giving of access would be in his/her best interests. Where the patient has died and the record included a note made at the patient s request that he/she did not wish access to be given to his/her personal representatives, or to any person having a legal claim arising from the patient s death. docs_ doc Page 68 of 85

69 E Cases where Partial Access may be Extended Where in the opinion of the holder of the record the information may cause serious harm to the physical or mental health of the patient, or other individual. Where information provided by a third party, who would be identified from their information. Where an application is on behalf of a child or pupil, or where the patient is incapable of managing his/her own affairs, or where a patient has died, access may be refused to that part of information provided by the patient, in the expectation that it should not be disclosed to the applicant, or where information was obtained as a result of examinations to which the patient consented in the expectation that the information would not be disclosed. Where a patient has died access shall not be given to any part of the record, which in the opinion of the record holder, would disclose information which is not relevant to any legal claim which may arise out of the patient s death. The whole, or part exemptions are the only circumstances in which access may be limited or excluded. F Definitions as per the Acts The Application an application in writing. Health Record the Health Record, and related expressions, are defined as being information relating to the physical or mental health of an individual who can be identified from that information, and which has been made by or on behalf of a health care professional, in connection with the care of that individual. The Holder of the Health Care Record is defined as being NHS Tayside or any other health care professional by whom, or on whose behalf, the record is held. The Health Professional the Health Professional is e.g.: A registered Medical Practitioner A registered Dentist A registered Pharmaceutical Chemist A registered Nurse, Midwife or Health Visitor A registered Chiropodist, Dietician, Speech Therapist, Occupational Therapist, Orthotist, Orthoptist, Physiotherapist or Prosthetist A Clinical Psychologist, a Child Psychologist An Art and Music Therapist engaged by the Board A Scientist engaged by NHS Tayside as Head of the Department G Administrative Procedure Where the patient or their representative wish to apply for access to their Health Care Records they shall be referred to the Records Manager or Practice Manager who will be responsible for the overseeing of the provision of access. There may be a fee for access and current charges are available from the Records Manager or from the Practice Manager in the case of access to GP records. Any charges will be notified in writing to the applicant during the access process and must be settled before access is arranged or any copies released. Where it becomes clear during the access process that the application is related to a potential negligence claim against the Board, the access process will cease immediately and advice sought from the Board's Legal Claims Manager. The access process may re-start but only on the advice of the Legal Claims Manager. docs_ doc Page 69 of 85

70 H PROCEDURE FOR HEALTHCARE PROFESSIONALS, GP PRACTICE MANAGERS AND RECORDS MANAGERS The following procedure should be followed when written or verbal requests for access to records are received. 1. Facilitate access during consultation or treatment, if appropriate. 2. Advise the patient or their representative that there is a requirement to complete an Application for Access to Health Records form, which will contain the vitally important details to enable checks to be carried out to ensure that the correct record is found. The patient should also be advised of the cost of the application as well as the response time to complete the request. 3. On receipt of the completed application form the Records Manager of GP Practice Manager will:- Check that the application form has been completed correctly by the applicant or by the representative of the applicant. Obtain the health record and refer to the appropriate health care professional for advice. If the information is old information and the health care professional is no longer available, the application should be referred to the appropriate Lead Clinician or Medical Director, or Head of Practice for GP Records. 4. The health care professional will, on receipt of the request for access to health records:- Advise the Records Manager or GP Practice Manager on the access to be allowed, ensuring that he has sought the views of other health professionals who had had a significant input into the patient s care. The health care professional should:- Decide whether to allow the patient to inspect the record (including the issuing of copy records). Decide if the patient may only see an extract, and if so, prepare the extract to be given to the patient. Advise the Records Manager or GP Practice Manager whether options (i) or (ii) are to be applied. Advise whether or not he considers he should be present when the patient is to inspect or receive the health record in order to provide explanations or counselling to the patient or patient s representative. Where the patient referred to is deceased, advise whether access to any part of the record preceding 1 st November 1991 should be allowed in order to make intelligible any part of the Record to which access will be given under the Act. The applicant has the right to have his request completed within 40 days of receipt of completed Application for Access to Health Records form. I Provision of Copy Records The Records Manager or GP Practice Manager will be responsible for ensuring that any photocopies required by the applicant are provided. docs_ doc Page 70 of 85

71 J Other Subject Access Requests Other Subject Access Requests include:- Court Orders Procurator Fiscal Police enquiries* Criminal Injuries Compensation Board Department of Work and Pensions enquiries Medical Reports Compensation Recovery Unit All the above are dealt with and processed by the Medical Records Department and, where appropriate, within agreed time scales e.g. within 7 days for a court order and if appropriate with the relevant Health Professional. * The sharing of information with Tayside Police is governed by the Sharing Information with the Police Arrangements and Guidance Protocol agreed between NHS Tayside and Tayside Police, further information on this protocol is available from the Information Governance Officer. K Complaints If the health care professional, GP, Records Manager or Practice Manager are advised by the applicant that they do not think NHS Tayside has complied with the Act, the applicant should be advised to contact the Complaints and Advice team. Reference Access to Health Records Act 1990 Data Protection Act 1998 Records Management:NHS Code of Practice (Scotland) Caldicott Principles Links Service Operating Procedure number 2:Confidentiality/Security and the Release and Management of Information PRIMAP Standard 4 (point 4.18) docs_ doc Page 71 of 85

72 NHS Tayside Health Records Service Operating Procedure Number 15: Filing of Loose Documentation 1. Opening Statement During the course of a patient s treatment within the hospital many documents and reports are produced by the various clinical and laboratory departments concerned with the patient s care. These documents and reports arrive at a variety of destinations within the hospital. Health Records, ward clerks and medical secretarial staff are responsible for ensuring loose documentation is timeously and correctly filed within the Health Record folder. 2. Health Records Department The Medical Records Department is not responsible for the filing of loose documentation in the Health Record. As far as possible all letters, laboratory reports, etc., should be filed at source. Staffs within the library area are responsible for the return of all loose filing to the location where it was produced. Where the documentation is to be filed in case notes outwith the site, e.g., a Perth patient is seen at Plastic Surgery Ninewells but without the Perth case notes any documentation produced from the consultation should be forwarded to the Records Library at Perth Royal Infirmary for inclusion in the notes. Health records filed within the libraries at Ninewells and Stracathro, should be requested to file loose filing in. The Mental Health Records Dept forward on to the locality where the record is being held any loose documentation for filing. 3. Medical Secretarial Level Secretaries should file all loose documentation within the Health Record before returning it to the filing library. If filing is generated after the records have been returned to file then the secretary needs to request the Health Record from the relevant filing library and file the loose documentation correctly in the Health Record on receipt. Alternatively, the secretary can go to the relevant filing library where the health records are housed. The accountability lies with the secretaries to carry out this procedure. 4. Ward Level Ward clerks should file all loose documentation within the Health Record before the record leaves the ward. In the event of Health Records not being available the ward clerk should pass on the paperwork to the appropriate secretary who should follow the procedure detailed in 3. above. 5. Accident and Emergency Reference Loose filing/documentation within the Accident and Emergency Department should be filed with the Health Record by the Accident and Emergency Secretary if there is one attached to the Department. If Health Records are not available on admission then the Accident and Emergency Secretary is accountable for tracing the record and filing into it accordingly. If the patient is admitted then the loose filing would go with the patient to the appropriate ward and would be filed in the Health Record by the ward clerk following procedure 4. above. Records Management: NHS Code of Practice (Scotland) 2010 Links PRIMAP Standard 3 (point 3.15) docs_ doc Page 72 of 85

73 NHS Tayside Health Records Service Operating Procedure Number 16: Registration of Patient Referrals on Patient Administration System Reference Records Management: NHS code of Practice (Scotland) 2010 Links Service Operating Procedure 5: Electronic Transmission of Patient Identifiable Data Service Operating Procedure 13: Searching and Updating Patient Demographic Data in the Master Patient Index. PRIMAP Standard 4 (points 4.12 and 4.31) NHS Tayside Health Records Service Operating Procedure Number 16: Registration of Patient Referrals on Patient Management System (PMS) STANDARD OPERATING PROCEDURE FOR TOPAS REFERRAL PROCESSES SOP NUMBER: VERSION NUMBER: 3 PREVIOUS VERSIONS: 2 EFFECTIVE DATE: REVIEW DATE: AUTHOR: APPROVED BY (1): DATE APPROVED: APPROVED BY (2): DATE APPROVED: Referral Governance Project Manager Referral Governance Facilitator Access Service Manager DOCUMENT HISTORY Version Edited by (job title): Number: 1 Referral Governance Project Manager 2 Referral Governance Project Manager 1. PURPOSE Effective Date: Details of editions made: Screenshots added Minor changes & timescales added The purpose of this standard operating procedure is to provide guidance around the recording of patient referral information in Topas - promoting good practice and hopefully achieving consistency of service. 2. APPLICABILITY This SOP applies to any staff member who inputs out-patient referral information into Topas and the processes around this. docs_ doc Page 73 of 85

74 3. PROCEDURE RMS ELECTRONIC REFERRAL PRINTING RMS referrals are printed at a location agreed and at this point the following steps should be taken to ensure no information is missed: Access the system as a Print User and select each of the following individually: PRINTING SPOOLER WITH NO ATTACHMENTS PRINTING SPOOLER WITH ATTACHMENTS PRINTING SPOOLER FOR BOOKING REQUESTS Print each list individually by selecting Print entire Queue. There is also the functionality to print an individual letter if required by selecting the print option alongside the patient s name. If a referral is printed individually please ensure this is noted when printing the whole list as figures will not tally when confirming the prints. docs_ doc Page 74 of 85

75 Once all queues have been printed, there could be attachments that were not recognised by the system. If this is the case an error message will appear and request SCI Attachments to action. This area is located on the left hand side of the screen and once clicked on, the attachments can be found and printed. When all queues are printed and all attachments are married up, logout switch account to Medical Records User for this location. Select Confirm Prints for printed letters with and without attachments and take a copy of the list of patients. Select Confirm Bookings for letters on-line screened by clinicians and take a copy of the list of patients. Carefully match up the list with the paper referrals to ensure all clinical information has been received. docs_ doc Page 75 of 85

76 CHECKING RMS CANCELLATIONS The cancellations page in RMS, should be checked regularly (every day). GP practices should be contacted, where necessary, to inform about the cancellation or to acknowledge the cancellation (referrals from out with Tayside do not receive the clinical information included in the cancellation details, therefore these practices must be informed). docs_ doc Page 76 of 85

77 PAPER REFERRAL LETTERS PAPER/FAX/BOARD TO BOARD/CONSULTANT TO CONSULTANT All paper referral letters received should be date stamped on arrival in Secondary Care (this includes at Unit Level). If the referral is received at Unit Level, Medical Records should be made aware of the referral as soon as possible (no longer that 36 hours from receipt but Saturday, Sunday and Public Holidays will be taken into account). Clinical advice (vetting info) should be provided to Appointments/Booking Staff as to the urgency, location of attendance and any special needs of the patient, (Diabetes, Hearing Difficulties etc), to allow the appropriate appointment to be made for the specialty. UK VETERANS Any patients who have suffered ill health or injury related to their past or current service are entitled to be fast tracked, providing there are no other patients with a greater clinical need. In addition to this, patients currently on a waiting list for in-patient or out-patient services, who are dependents of Service Personnel, and move Health Board, are entitled to be placed back onto the same place on the Waiting List in the new Health Board. For electronic referrals GPs should tick the if patient is an armed forces veteran please tick this box (this should be selected if the patient is Veteran, current or past, or the patient is a dependant of a Veteran e.g. son, daughter, wife) or this may be indicated in body of the referral letter, for both electronic or paper referrals. Where possible, Clinical staff should manually highlight this when screening the referral. Information on Veterans flags should be sent to Linda Fox, lindafox@nhs.net and Heather Anderson, heatheranderson@nhs.net including patient s name, CHI, location & speciality of referral, GP and screening information to allow the patients to be appropriately dealt with. docs_ doc Page 77 of 85

78 ADDING ALL REFERRALS TO TOPAS ALL referral letters (paper, screened or non-screened) should be added to Topas on receipt (with 24hrs of receipt) by Referral/Appointment staff in Secondary care there should be no delay waiting for vetting or tests etc. Referrals which have been cancelled should still be added to Topas and filed in the patient s case notes, even if this means raising new case notes. Check Patient Details Before adding a referral (paper or electronic) onto Topas the Patient Details screen should be accessed to ensure all the demographic information (including GP) for this patient is accurate and saved into the system. ADDING A REFERRAL Date of Receipt of Referral a) RMS referrals - this is the date the referral has arrived electronically from General Practice to Secondary care, which is the submitted date (unless the referral has hit the SCI Deadmessage file, in which case the Referral Governance Team will inform Medical Records to allow information to be accurately input into Topas). b) Paper referrals - this is the date received by secondary care which should be date stamped on receipt by either medical records or Unit level, whichever is first. c) Bowel Screening Service Referrals - this is the date of the SCI-Gateway referral d) Cervical Screening Colposcopy Referrals - this is the date the abnormal smear result was reported. e) EMS Recall this is the date of report of the chest x-ray Serial Number This is for RMS referrals only and is the number quoted along the top of the referral prefixed by a T e.g. T The serial number should only be recorded on Topas against one referral. If the Clinician has indicated more than one condition or more than one attendance pathway the first consultant attendance should be recorded as a GP source of referral, any tests should be recorded as a Consultant referral. Any Test only appointments should be recorded as a GP referral. The T number should only be recorded against the GP referral. Requested Consultant Name of the clinician referred to by General Practice if quoted Requested Specialty Name of the specialty referred to by General Practice e.g. C5 ENT Requested Priority a) RMS Referrals - this is the priority selected by General Practice e.g. Urgent or Routine (at present all Urgent Suspected Cancer should be added as Urgent ). docs_ doc Page 78 of 85