Records

Records are an essential part of health and care.

Records and the information they contain, and the proper management of such records, are vital to the delivery of good quality healthcare services to our patients and delivery of our business activities. Our records are our lifeblood and corporate memory, providing evidence of the actions and decisions made in the provision of our healthcare services and business activities. Additionally, compliance with current Data Protection legislation and the Freedom of Information Act 2000 puts good records management high on the corporate agenda.

Records management is a discipline which ensures all staff within the Trust are responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposal of records, whatever format or media type they are held in. Information is only usable if it is correctly and legibly recorded in the first place, is then kept up-to-date (contemporaneous) and is easily and readily accessible when needed.

To help ensure that these records are all managed consistently, the Trust follows the Records Management Code of Practice for Health and Social Care 2021. This provides important information to those responsible for managing records on how to file and store records and how long records should be kept for.  The Code of Practice provides a framework for consistent and effective records management based on established standards. It covers all types of NHS and adult social care records (where the social care provision has an element of NHS funded care) regardless of the media on which they are held, including for example:-

• All patient health records for all specialties
• All administrative records (for example personnel, estates, finance and accounting, customer services, complaints, incidents, etc.)

These include records held in all formats, including for example:-

• Electronic records
• Paper records, reports, diaries and registers, etc.
• X-rays and other images
• Audio and video recordings
• Microfiche and microfilm

All NHS records are public records under the Public Records Act 1958 and each member of staff is responsible for the records they create or use.

The Trust has a responsibility to ensure that the healthcare each patient receives is recorded appropriately and accurately, and that records are processed responsibly to support high quality care. There are Trust standards for record-keeping, supported by professional standards for clinical record-keeping that are part of the requirements for professional registration. Additionally, for legal and practical reasons, records must be stored and transported securely.

The Records Management Code of Practice was introduced to ensure that organisations manage their records at all stages of the records lifecycle from the point of creation, through active use and retention, to either ultimate destruction or permanent preservation if being of historical or research interest.

The Records Team is part of the Information Governance Team and can be contacted directly by emailing Records@merseycare.nhs.uk (General Enquiries) or Records.Team@merseycare.nhs.uk (Everton Road).

To help ensure that records are all managed consistently, the Trust follows the Records Management Code of Practice. This provides important information to those responsible for managing records on how to file and store records, how long records should be kept for (minimum retention periods) and arrangements for disposal.  The Code of Practice provides a framework for consistent and effective records management based on established standards. It covers NHS and adult social care records (where the social care provision has an element of NHS funded care).

The Section 46 Code of Practice of the Freedom of Information Act 2000 also provides guidance on good practice in records management.

BS 10008 Evidential Weight and Legal Admissibilty of Electronic Information is the British Standard that outlines best practice for the implementation and operation of electronic information management systems, including the storage and transfer of information. It is designed to ensure the authenticity and integrity of electronic information to avoid the legal pitfalls of information storage. BS 10008 outlines best practice for transferring electronic information between systems and migrating paper records to digital files. It also gives guidelines for managing the availability and accessibility of any records that could be required as legal evidence.

The over-arching Corporate Records Policy (IT04) and Health Records Policy (IT06) are available via the Trust's website.

Both these policies are supported by local procedures and guidance that provide more information on records management, record-keeping, archiving and retention. Please note that these documents may be Trust-wide or division specific.

Please note that some documents are in the process of being reviewed, updated and rebadged and, therefore, the links to them are not curretly operational. In the meantime, if you require copies of any of these such documents, please email the Records Team.

There are often ongoing national inquiries that need to be considered when reviewing and appraising records as part of the record lifecycle. The current inquiries that all staff need to be aware of are:

The Independent Inquiry into Child Sexual Abuse (IICSA) has requested that large parts of the health and social care sector do not destroy any records that are, or may fall into, the remit of the inquiry. Investigations will take into account a huge range of records which may include, but are not limited to, adoption records, safeguarding records, incident reports, complaints and enquiries. Outside of this inquiry, it is also important to consider that these records are likely to require longer than the standard retention periods given in the Code of Practice. Before any records are reviewed and considered for destruction, you must contact the Records Team who will check for any further update from the inquiry website.

The Infected Blood Inquiry has requested that the health sector do not destroy any records that are, or may fall into, the remit of the inquiry. Before any records are reviewed and considered for destruction, you must contact the Records Team who will check for any further update from the inquiry website.

The Trust uses a number of off-site, secure storage companies to hold and store records, as follows:

New records awareness training package

The records team have launched a new records awareness training package to make sure we are all working in the same way to protect our patients, colleagues and the Trust.

What will you learn?

• Who the records team are and how they can help
• Records policies and procedures
• Understanding BS10008 (the British Standard)
• How to scan and upload a document to an Electronic Patient Record (EPR)
• How to quality check and confidentiality destroy documents
• What a 'confused record' means
• Confidentiality 
• Retention periods
• Lost, stolen or duplicate records and incidents
• National inquiries and what this means for us
• Archiving processes and record retention periods
• How to process an amendment to record requests
• When to complete a Radar
• How to access patient records
• Intoduction to user group.

How to book onto a session

To book on a session, please visit the Training Courses Booking App.

From here, please select 'Information Governance' for the system and 'Records Management Awareness' for the course name.

Once you have selected a suitable date, you will be sent a Microsoft Teams meeting invitation to enable you to join the online training.

Should you require any further information, please email: records@merseycare.nhs.uk