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 and 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/20269/6962

Emis Web -  Patients should be registered with a Smartcard to enable the patient to be selected from the PDS, to ensure the record is linked to the NHS Spine. This will;

•Maintain the single record for the patient
•Prevent misidentification
•Prevent duplicate records
•Improves data quality at source
 
Manually created records for a patient are not liked to the GP or shared records so do not provide consistency of care.
 
RiO - Once a patient's record is opened in RiO, any changes to the patients' demographics, will be highlighted on the right-hand side. Therefore, you should then be updating this to ensure we have the most current information. 
 

Failure to do this can result in;

  • Letters being sent to the wrong patient
  • Not having the correct contact information

This in turn can;

  • Breach confidentiality
  • Referrals being rejected
  • Delays to patient care
  • Missed appointments etc
 
MISCONCEPTIONS
 
  • Updating patient demographics on the NHS Spine does not automatically update the GP clinical system record (e.g. EMIS Web).
  • A mismatch will be flagged via the GP record PDS indicator, and the local record must be reviewed with the patient and updated to align with the Spine.
  • This reinforces the need for PDS checks and supports data quality and patient safety.
 

To ensure the correct information is being recorded in staff diaries, and that the Health Records Policy guidance is being followed around transportation and storage of staff diaries. Whilst we do understand that staff need to record patient appointments, they should, wherever possible, use digital diaries (preferably in the relevant clinical information systems, but using Microsoft Outlook if this is not possible) which are then accessed via Trust IT equipment.  Where this is not possible or practicable and paper diaries are necessary for a member of staff to perform their role, they must implement the following process, effective immediately.

  • The front page of the diary must contain the member of staff’s name, job title and work telephone number in case the diary is stolen or lost.
  • Only the name of a patient and their appointment time can be entered in the diary – no other information (eg demographics or clinical details) relating to that patient should be recorded.
  • Notes from appointments must be written on something disposable (eg a continuation sheet).  This sheet can contain the patient’s name, address, key safe access code and telephone number, if required.
  • Any continuation sheets, and other necessary documentation (eg clinic lists) must be contained within a lockable/secure bag/case during the visit(s).  Staff must make every effort to ensure the security of the bag/case at all times.  It must not be left on view in unattended vehicles and should be locked away if kept at home overnight.
  • When staff next return to their base, they must ensure that any notes taken are immediately transferred to the relevant clinical information system.  Once they have been transferred, the continuation sheet must be confidentially destroyed (eg shredded).
  • If the notes are inputted more than 24 hours after they were taken, they must be added as retrospective entries with a reason given as to why there has been a delay in updating the record.
  • The retention period for these diaries is two years.  At the end of the calendar year, staff must securely retain their diaries in their office for two years and then arrange for them to be confidentially destroyed (please see the IT06 Health Records Policy for guidance).
  • If the member of staff leaves the Trust, they must return their diary to their line manager along with their IT equipment.  The line manager must then retain the dairy for the appropriate period of time.

 

Record Keeping Policy Guidance: Records of any description must NOT be left in vehicles overnight. All care records and professional diaries must be returned to their identified base at the end of the working day. However, it is recognised that sometimes visits are undertaken towards the end of a normal shift with the staff member’s base being closed upon return. If this is unavoidable the number of records must be kept to a minimum and the staff member is responsible for ensuring patient confidentiality is not compromised. Records must be kept secure and stored in a safe place within the member of staff’s home, inaccessible to family members. They must be returned to their normal location the following morning and the relevant tracking system updated, if applicable.

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