9 September 2024

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, staff and the Trust. Find out more and book your place by using the button below.

Records awareness training package

Destruction of patient or staff related information

The Records Team would like to remind all staff not to destroy any patient related paperwork or electronic documentation whilst there are continuing ongoing inquiries.

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

The are numerous Inquiries ongoing:

  1. Infected Blood Inquiry
  2. IICSA Inquiry
  3. Covid 19 Inquiry
  4. Lampard Inquiry
  5. 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.

What does this mean for the Trust?

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 or 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 you need any advice or support with this, please contact records@merseycare.nhs.uk

Uploading emails

If you discuss patient care within an email, this email must be uploaded to the EPR (Electronic Patient Record).

Record keeping policy guidance

Please do not  copy and paste entire email trails and documents into progress notes or clinical entries in the EPRs. 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
  • An uploaded email forms part of the EPR and is therefore accessible to the patient should they request access to 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.

 

 

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