PROCEDURE FOR THE STORAGE, TRANSFER AND TRACKING OF RECORDS CONTAINING PERSONAL INFORMATION.
Eve Scott & Pat Patrice Prepared by:
Responsible Area:
Corporate Services Directorate Date Approved:
Approval Information: COMMITTEE:-
Approved By:
Reference to Standards for Better Health Domain
11th October 2007. Governance Committee Sign
Director
Print Name
Helena Corder
Version No. Approved:
V1
Review Date:
April 2010
C9
Core/Development standard Performance indicators
History of Document
1. all records appropriately stored or archived as demonstrated at audit 2. no adverse incidents regarding security of the record during storage or transfer. 3. all records successfully recalled from archiving as required.
CONTENTS Section headings
Page
Introduction
3
Associated Policies and Procedures
3
Aims & Objectives
3
Definition of a Clinical Record
4
Storage of Live Records
4
Transfer of Live Records
4
Tracking Systems for Live Records
4
Transfer of Records
5
Confirmation of Receipt of Records
6
Storage of Closed Records
6
On-Site Storage of archived records
6
Off-Site Storage
7
Retrieval of a record from archive
7
Breaches in Security
7
References & Bibliography 7 References & Bibliography
7
Appendices
8
Consultations with individuals/groups or subcommittees
9
2
1.0
Introduction This procedure lays out the content and format for the storage, transfer and tracking of clinical records and maintained by PCT employed staff. All items which may become part of a record, such as statements, letters and diaries, should also conform to this policy. It is one of a set of procedures that underpins the Kirklees PCT’s Records Managements Policy and as such must be complied with by all directly employed staff of the two PCTs. It is offered to the independent contractors as ‘best practice’ for them to use as appropriate in their sphere of responsibility. The PCT expects good record management across all Services and each Clinician has a key role in maximising benefits to patient care through effective record keeping.
2.0
Associated Policies and Procedures This procedure should be read in associate with the following PCT policies, procedures and guidance: • Confidentiality Policy Statement & Guidance • Freedom of Information Policy • Incident Reporting Policy It should be used in conjunction with the following records management procedures: • Procedure for access to records • Procedure for the structure and format of a clinical record • Procedure for the 24 hour access to Clinical Records
3.0
Aims & Objectives This procedure aims to ensure that all records containing confidential (person identifiable) information are: • stored securely when live • can be tracked during use or transfer • are archived securely when closed • can be recalled from archive efficiently should they be needed for reference / reuse
3
4.0
Definition of a record A record is anything that contains information, in any media, eg paper, microfiche, audio or video tape, x-ray images, computer database notes, ie email etc, which form part of the clinical record which has been created or gathered as a result of the delivery of clinical care to an individual. This includes any progress notes, written on any medium which services may record to a patient receiving services from the PCT or as part of a package of care in conjunction with another agency.
5.0
Storage of Live Records Clinical Records. When a record is in constant and regular use, it should be stored within the appropriate Health Centres or Clinics. These records should be stored within filing cabinets. When a room containing records is left unattended, it should be locked. A sensible balance should be maintained between the needs of security and accessibility. When filing records, this should be done in either chronological or alphabetical order. Personal (HR) Files Personal files are stored in a locked cabinet at PCT Headquarters building until they are delivered by a member of the HR Directorate to the appropriate line manager. They should again be stored securely in a locked filing cabinet or cupboard when not in use.
6.0
Transfer of Live Records Where records are transferred within the PCT or from or to other PCTs, the entire record should be kept intact and a tracking system used. Accurate recording and knowledge of the whereabouts of all records is essential if the information they contain is to be located quickly and efficiently. One of the main reasons why records get misplaced or lost is because their next destination is not recorded anywhere. It is important that any tracking system meets user needs and is adequately supported. The success of the system depends on it being up to date, therefore all staff should be made aware of its importance and receive adequate training in its use to ensure that it is kept up to date.
6.1
Tracking Systems for Live Records All live records held by the PCT must be subject to a tracking system. This should be one of the following: • • •
Electronic register A paper register – a book or dedicated diary An index system with a card for every absent record, held in alphabetical order 4
Where records have been removed from a file, an absence or tracer card should be put in place. The following information should be recorded: • • • • 6.2
Name of the record removed from the system Name of the recipient of the record, their job title and contact details The date of the transfer and the date they should arrive Confirmation from the recipient that they have arrived
Transfer of Clinical Records
Within the PCT. If it is absolutely necessary to transport paper notes or print outs which contain person identifiable information within the PCT, please make sure you transfer them within a sealed envelope and that “Confidential” is marked in a prominent place on the front of the envelope. Parcel tape should be used to seal the envelop and a signature should be made across the tape, to ensure that any attempt to tamper with the envelop is immediately visible. Transit envelopes should NOT be used. Ensure that the address of the recipient is correct and clearly stated using the following format: • • • • • •
Full name Designation (job title) Department Organisational address Write a return address on the back of the envelope Include a compliments slip with your contact details where feasible
NEVER leave patient notes, X-ray packets, laboratory reports, letters, or any material containing confidential personal information unattended at any time whilst in transit. You are responsible for their safe arrival. Any members of staff who are required to transport confidential records across PCT sites must ensure they are stored in a closed case, are not on view and must exercise vigilance at all times during their transportation. Vehicles must always be locked if they are left unattended. By Internal Post If person-identifiable information is to be sent, the envelope must be sealed and marked “Confidential”. Internal mail should still be properly named and addressed. Include a compliments slip with your contact details and a return address on the back of the envelope. 5
Please take particular care when using window envelopes to send person identifiable information either in the internal post or the external post. Ensure that only the appropriate details i.e. the name and address of the person you are sending the envelope to, can be seen. All PCT employees have a duty to uphold confidentiality and to respect the right of others to have their personal information managed as strictly confidential at all times. Where a patient is admitted to Acute Care and the District Nurse records are sent with them, the standard receipt proforma must be completed (Refer Form RM6). The receiving unit must fax a signed copy to the appropriate district nursing team (refer section 6.3 below). Where patients care is either transferred to another care provider eg private sector housing association or discharged to another healthcare provider or PCT, careful consideration must be given as to the type of information provided regarding the care and treatment of that individual. Where complete Medical Records are to be transferred/loaned, this must be via a secure system of transfer, either via an in-house post delivery system or by recorded mail. 6.3
Personal (HR) Files Personal files should be hand delivered to their destination by a member of the Human Resources Directorate.
6.3
Confirmation of Receipt of Records When a record has been transferred, a confirmation of receipt should be completed by the receiving team or organisation and faxed back to the transferring team. If this is not received within 24 hours of the expected receiving date, a telephone call should be made to assure that it has arrived. If the record has not arrived, an incident reporting form should be completed.
7.0
Storage of Closed Records When records are no longer in constant use they may be archived. All records selected for archiving must be: • • • • •
Securely boxed in appropriate archive boxes. Boxes will be supplied, two at a time, from reception at either St Luke’s House (01484 466000) or Beckside Court (01924 351600 & ask for Corporate Services Administrator) Within each box, records must be in either alphabetical order or chronological order by years or months All parts of the patient record must be securely bound with parcel string and no loose pages placed in boxes. Boxes must be clearly labelled using Form RM5 and small address label 6
• • • •
Boxes will be archived by year with a destruction date (see Appendix A for retention periods) Children and Family Health Visitor records must be archived in separate boxes Records of adults patients / clients must also be stored in separate boxes. Requirements 7 & 8 are due to differing retention periods. Each box must be accompanied by an RM02 form completed electronically. It is the responsibility of the clinical team to ensure that the RM02 form is fully populated.
7.1
On-Site Storage of archived records
7.2
Local procedures must be in place to ensure that all records are kept secure prior to being sent for HQ storage e.g. patient records in a locked cabinet. Until such time as the record has been entered onto the PCT’s archive database, it must have a tracking card. Responsibility for archiving records on-site will lie with the named person for records management on your site (see Form RM1). Form RM1 MUST be up-to-date and displayed in a prominent position, such as the main reception area, where it is easily accessible for all staff. Off-Site Storage Off site storage of records is the responsibility of the corporate services team. For the archiving of records off-site refer to flowchart (see Appendix B)
7.3
Retrieval of a record from archive Form RM4 must be completed and forwarded to reception at either St Luke’s House or Beckside Court (FAO Corporate Governance Administrator). The required record will be retrieved from storage by a member of the corporate services team and forwarded to the requesting team within 3 days of the request arriving with the Corporate Governance Administrator.
8.0
Breaches in Security Any lost records / breaches in confidentiality must be reported in accordance with the Incident Reporting Procedure. These will be investigated by the Corporate Services team and /or the Information Security team. All learning points will be cascaded across the PCT.
9.0
References & Bibliography
7
Appendix A Extract From NHS Records Management: Code of Conduct Part 2 Calculation of Retention Periods. Retention periods should be calculated from the 1st January the following year e.g. for 2005 records which are to be kept for 8 years then they will have the destruction year of 2014 (2006 + 8 = 2014). The retention periods listed below reflect minimum requirements for clinical need. Personal health records may be needed as evidence in legal actions: the minimum retention periods take account of this requirement. Record Type Children and young people
Retention Period Until the patient’s 25th birthday, or 26th if young person was 17 at conclusion of treatment; or 8 years after patient’s death.
Diaries
2 years (with non-clinical information) 8 years (with clinical information) NB: Patient relevant information should be transferred to the patient record and retained for the appropriate time period
District Nursing
8 years
Family Records
10 years (if relate to children, retain for appropriate time period)
Health records (not covered in this section)
8 years after conclusion of treatment
Health Visiting
10 years (if relate to children, retain for appropriate time period)
This list is not exclusive. If in doubt, check against NHS Records: Code of Conduct Part 2. This can be found at the following web address: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digital asset/dh_4133197.pdf
8
Appendix B
Archiving and Retrieval of Patient Records Flowchart Part 1 Empty boxes can be obtained from the Reception Staff at Beckside Court and St. Lukes House
Fully fill record box Use marked storage boxes ONLY (Provided by the PCT) Archive ADULT/CHILDREN and FAMILY in SEPARATE BOXES Archive diaries in separate boxes Records from a different year should not be mixed in one box Label the box with name of Trust, Service, Health Centre or Site, Record type (eg District Nursing/Health Visiting), year (eg 2003 A-J) and Year of Destruction (see Appendix A)
Keep comprehensive record of all files sent for archiving (Complete Form RM2 (Patient Records Archiving Form) and place a copy in a sealed envelope attached to the box
Use Form RM3 and inform Reception Staff at HQ that an Archive box has been sent (If no confirmation of receipt received from HQ within 2 days, then contact directly)
9
Part 2
STEP 1
Y
Are the records clearly identifiable by NHS number, patient surname and date of birth
Ensure that the records are clearly identifiable
N STEP 2
Are the individual records securely bound together (preferably in plastic wallets, elastic bands are NOT to be used).
Y
Ensure the records are securely bound
N STEP 3
Have the contents of the boxes been clearly identified and recorded on an alpha numeric basis including NHS number, surname, date of birth and a local reference number.
Y
Sort the records into alpha numeric order and record the NHS number, surname and date of birth for each record
N Y
STEP 4
Were the children, of the records to be stored, all born in the same year?
Ensure that all records are from the same birth year (January -December)
N STEP 5
Is the box clearly marked as to which year it refers, the birth year of the child to which service it belongs and the year of destruction.
Y
Ensure that the boxes are clearly marked
N STEP 6
If the records relate to adults, follow steps one to three. Clearly identifying the service to which the records belong on the exterior of the box. N STEP 7
Has a copy of the authorised signatory list been included in the box?
Y
Place a copy of the list collated at step 3 in the box
10
STEP 8
Y
Has a copy of the authorised signatory list been included in the box?
Include a copy of the signatory list
N STEP 9
Forward the box(es) to the Records Manager N STEP 10
Is the Records Manager satisfied that steps one to eight have been carried out?
Y
Return box(es) to the originator, explaining what action needs to be taken.
N STEP 11
Record box details on central data base cross referencing to any reference provided by the storage company N STEP 12
Place box(es) into storage and advise originator of their location.
11
Retrieval Flowchart Ensure that the record you want to retrieve has been sent for archiving and is not currently being stored on site
Complete Form RM4 and contact Reception Staff at HQ
12
FORM RM1
RECORDS MANAGEMENT The person responsible for Records Management in this Team is:
Patient Records Archiving Form Service/Team: Location: Lead/Team Co-ordinator:
Records Archived by: NHS Number)
Patients Name
D.O.B.
Year
Record Type
Date for Destruction
Signature
Full Name
FORM RM3
TRACKING RECORD DATE
BOX DETAILS (Use box Label)
SENT TO
SENT BY
CONFIRMATION OF RECEIPT
SIGNATURE
FORM RM4
COMMUNITY RETRIEVAL REQUEST FORM DATE REQUESTED
PERSON REQUESTING RECORDS
S:\Records Management\Form RM4
REASON FOR REQUEST (Solicitors request, Continuation of treatment)
PATIENT NAME/DOB
NAME OF PERSON TAKING REQUEST
FORM RM4a
HQ RETRIEVAL REQUEST TRACKING FORM DATE
PERSON REQUESTING RECORDS
S:\Records Management\Form RM4
REASON FOR REQUEST (Solicitors request, Continuation of treatment)
PATIENT NAME/DOB
NAME OF PERSON TAKING REQUEST
DATE RECORD SENT
Confirmation of Receipt Given
DATE RECORD RETURNED
FORM RM5
TYPE OF RECORDS: (Health Visitor/District Nursing/Family/Children’s etc)
TYPE OF RECORDS: (Health Visitor/District Nursing/Family/Children’s etc)
SERVICE/TEAM: (Name of Health Centre, GP Surgery, Clinic etc)
SERVICE/TEAM: (Name of Health Centre, GP Surgery, Clinic etc)
YEAR: (Years to be kept separately)
YEAR: (Years to be kept separately)
DESCRIPTION: (Take Offs/Births/Diaries etc – boxed separately)
DESCRIPTION: (Take Offs/Births/Diaries etc – boxed separately)
DESTRUCTION DATE: (for example, if records to be kept for 8 years from date of dismissal etc then use st 1 Jan ie 1997 records to be destroyed Jan 2006)
S:\Records Management\Form RM4
DESTRUCTION DATE: (for example, if records to be kept for 8 years from date of dismissal etc then use st 1 Jan ie 1997 records to be destroyed Jan 2006)
FORM RM6
RECEIPT OF DISTRICT NURSING RECORDS
Patient’s Name:………………………………………………………………………………………. Patient’s NHS Number:………………………………………
District Nursing Team:…………………………………….… Address:……………………………………………………………………………………………….. Fax No:………………………………
I acknowledge receipt of the District Nursing Records for the above named patient. These records will be returned to the above District Nursing Team.
Signed:……………………………… …. Name:………………………… ………… Job Title:……………………….………… Contact No:………………………….….. Date:……………………………….…….
This form should be faxed back to the District Nursing Team on the above number S:\Records Management\Form RM4
Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible for revision Primary Circulation List Web address
Restrictions
Procedure for Storage, Transfer & Tracking of a Record TBC Eve Scott and Pat Patrice N/A V1.1 th 27 April 2007 April 2010 Records Manager All staff notified via team brief http://www.kirklees-pct.nhs.uk/publicinformation/publications/policies-and-procedures/informationgovernance/ None
S:\Records Management\Form RM4