Please ensure you are familiarised with the records processes followed at the trust. Reminders of these and other key information is available below:

Archiving Process from August 2025 

  • Email us to receive electronic archiving listing sheet & Guidance Document ​​​​ ​​​​​​records@merseycare.nhs.uk 

  • Records Team to order boxes via Iron Mountain to be delivered directly to requesting Team 

  • Requesting team to ensure each patient within the box is listed electronically on the archiving sheet – one box per tab.  Requesting team to retain a copy and a copy returned to The Records Team. 

 

PLEASE NOTE: Ensure you update your EPR (RiO) PDT system or any other manual / electronic tracking system 

  • Each box needs our Trust account code written on – EM500 

  • Records Team to order barcodes via Iron Mountain (to have a bulk order based at Hollins Park Library) 

  • Records Team to send barcodes directly for team to add to the boxes. Record Team will allocate the barcode number to each box 

  • Records Team to liaise with team and Iron Mountain for suitable collection date.  

  • Requesting team then need to scan and save receipt from Iron Mountain – a copy for them and a copy sent back to The Records Team (Records Team to save G:Drive 12.8.16) 

 

Retrieval of records from off-site Storage

  • Email Records Team to receive a records retrieval form records@merseycare.nhs.uk  

  • Completed form and return will all fields complete – box and barcode numbers etc 

  • Record team to request via iron mountain and arrange for box(s) to be delivered to Team 

  • Team to email Records Team to confirm receipt and expected return date 

  • Once Team have finished with the box(s), email Records Team to arrange collection ensuring all files are placed back in the correct box(s) and confirm collection  

 

Purpose: A confused care record is where one patient’s information is recorded in another patient’s record and the incorrect information must be removed and/or deleted from the record. It is the responsibility of staff within the Trust to ensure care is taken when removing and merging documentation and information in the care record.

 

Record Keeping Policy Guidance: If a care record (paper or electronic) is found to contain another patient’s information (including scanned documents):

  • You must inform your line Manager
  • A qualified Clinician must review all documentation and entries found to ensure that the patients involved have not been harmed, as this is a risk to patient safety
  • A Radar incident must be created for all ‘Confused Care Records’ ensuring that you select the Records Team as a reviewer
  • The Radar report must include the NHS numbers
  • Staff must transfer the information to the correct patient’s care record.

If you require any further assistance or have any queries please contact the Records Team – General Enquiries – records@merseycare.nhs.uk

Purpose: Where an individual considers information contained in their records to be inaccurate, incorrect, misleading, or incomplete, they may apply for a correction to be made. In all situations where an individual disagrees with the content of their record(s), a note (addendum) must be added to their record(s).

Record Keeping Policy Guidance:

  • An individual can make a request for rectification verbally or in writing.
  • Upon receipt, the Trust has 31 calendar days to respond to the request.
  • A RADAR must be completed for all Amendments to Records requests.
  • An amendment will only be completed if found to be factually incorrect, for further information / support with a request for amendments to records please contact us - Records@merseycare.nhs.uk

Purpose: The Records Team would like to remind all Teams/Services not to destroy any patient related paperwork or electronic documentation whilst there are continuing ongoing Inquiries.

 

NHS England have instructed organisations that no documentation potentially in-scope of the Inquires can be destroyed.

 

The are numerous inquiries ongoing:

  • Infected Blood Inquiry
  • IICSA Inquiry
  • Covid 19 Inquiry
  • Lampard Inquiry
  • The Independent Inquiry into issues raised by the David Fuller case.

Final reports and recommendations will be published by NHS England, following the conclusion of each enquiry.

Record Keeping Policy Guidance: The Trust must ensure that everything of potential relevance to Inquiries is retained until the Inquiries are completed.  This includes patient, staff and Occupational Health records, divisional arrangements and documentation, all correspondence, notes, emails, minutes, text messages, Teams Channels/Chat and any other information, however it is held (either electronic or paper).  This is Trust-wide and covers all divisions (operational and corporate).

 

Local Guidance: The following guidance sets out the high-level areas that may potentially fall within the scope of the Inquiry and therefore require consideration when undertaking records management or if staff are leaving the Trust.

 

Documentation: The following list shows the sort of documents that may be in-scope of the Inquiries.  This list is only intended to be indicative, not exhaustive.  If there is uncertainty about a document, the Records Team should be contacted for advice (contact details are at the end).

  • All patient records (mental health, secure, learning disabilities, CAMHS, community, etc), whether the patients are living or deceased, including clinical reports and statements and any safeguarding/Covid-19 alerts.
  • Vaccination logs and Infection Prevention and Control records
  • Minutes of meetings where decisions were made regarding the pandemic.
  • Cleaning records and other Estates-related items (eg closure of buildings, signage, etc)
  • Communications with staff, volunteers, locums, etc
  • Communications with partner organisations, agencies and contractors
  • Communications with patients and other service users (eg carers)
  • Purchase orders and contracts
  • Material relevant to the development of policies and procedures
  • Material relevant to the development IT systems and changes
  • Decisions made at Gold, Silver and Bronze Command meetings
  • Incident reports (including serious incidents)
  • Staff records (including Occupational Health, local personnel files and central records held by Human Resources)
  • Correspondence in relation to the pandemic and any arrangements or agreements
  • Staff supervision notes
  • Any other appropriate documentation as determined by staff.

If staff need any advice or support with this, they can contact the Records Team by emailing records@merseycare.nhs.uk.

Purpose: If staff discuss patient care within an email, this information MUST be uploaded into the patient’s EPR (Electronic Patient Record).

Record Keeping Policy Guidance: Staff must not copy and paste entire email trails, or documents, into progress notes or clinical entries in the EPR. If an email or other document is pertinent to the patient’s record, it must be saved and uploaded as a document into the EPR (Electronic Patient Record) and then a reference made in the clinical entry. (In RiO, the email/document must then be associated to the progress note.)

Key Points:

  • Patient names must not be used within the email – the NHS Number is the unique identifier and should be used for this purpose.
  • Staff should be aware that an uploaded email forms part of the EPR and therefore is accessible to the patient should they request to access their records.
  • Care should be taken when recording information within the email to ensure the information is accurate, in plain English and without the use of jargon or abbreviations.

 

You can find the current list in the attached document found in the link below

https://yourspace.merseycare.nhs.uk/download_file/view/18928/6962

For any enquiries, email Records@merseycare.nhs.uk