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Records Management: NHS Code of Practice (Scotland) Version 1.0

DescriptionRecords Management best practice in relation to the creation, use, storage, management and disposal of NHS records
ISBN
Official Print Publication Date
Website Publication DateJuly 04, 2008

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ISBN 978 0 7559 1750 1 (Web only publication)
This document is also available in pdf format (688k)

Contents

SECTION 1 - FOREWORD
Background
Aims
Types of Record covered by the Code of Practice

SECTION 2 - INTRODUCTION
General Context
Legal and Professional Obligations
NHSScotland eHealth Strategy
Social Care Records

SECTION 3 - NHS RECORDS MANAGEMENT
Management and Organisational Responsibility
Policy and Strategy
Record Creation
Information Quality Assurance
Record Keeping
Record Maintenance
Scanning
Disclosure and Transfer of Records
Retention and Disposal Arrangements
Appraisal of Records
Record Closure
Record Disposal

ANNEX A - GLOSSARY OF RECORDS MANAGEMENT TERMS
Access
Appraisal
Archives
Authenticity
CHI Number
Classification
Conversion (See Also Migration)
Corporate Records
Current Records
Destruction
Disposal
Disposition
Electronic Record Management System
File
Filing System
Health Record
Indexing
Information Audit
Information Survey/Records Audit
Integrity of Records
Jointly Held Records
Metadata
Microform
Migration (See Also Conversion)
Minutes (Master Copies)
Minutes (Reference Copies)
NHS Records
Paper Records
Permanent Retention
Presentation
Preservation
Protective Marking
Publication Scheme
Public Records (Scotland) Act 1937
Records
Records Management
Record Series
Record System/Record-Keeping System
Redaction
Registration
Retention
Review
Scottish Information Commissioner (See Also UK Information Commissioner)
Scottish NHS Archivists
Tracking
Transfer Of Records
UK Information Commissioner (See Also Scottish Information Commissioner)
Weeding

ANNEX B - RESOURCES TO SUPPORT IMPROVEMENT
The Role of the Information Governance Framework and the Information Governance Toolkit
Other Reference Material
Useful Contacts

ANNEX C: LEGAL AND PROFESSIONAL OBLIGATIONS
Legislation
1. Anti-Terrorism, Crime and Security Act 2001
2. The Abortion (Scotland) Regulations 1991
3. The Access to Health Records Act 1990
4. The Access to Medical Reports Act 1988
5. The Census (Confidentiality) Act 1991
6. The Computer Misuse Act 1990
7. The Consumer Protection Act ( CPA) 1987
8. The Control of Substances Hazardous to Health Regulations ( COSHH) 2002
9. The Copyright, Designs and Patents Act 1988
10. The Crime and Disorder Act 1998
11. The Data Protection Act ( DPA) 1998
12. The Disability Discrimination Act 1995
13. The Electronic Communications Act 2000
14. The Environmental Information (Scotland) Regulations 2004
15. The Freedom of Information (Scotland) Act 2002 ( FOISA)
16. The Gender Recognition Act 2004
17. The Health and Safety at Work Act 1974
18. The Human Fertilisation and Embryology Act 1990, as Amended by The Human Fertilisation and Embryology (Disclosure of Information) Act 1992
Find out more here
19. The Human Rights Act 1998
20. The Human Tissue (Scotland) Act 2006 - Part 1 Section 19 and Part 3
21. The Local Electoral Administration and Registration Services
(Scotland) Act 2006
22. The Mental Health (Care and Treatment) (Scotland) Act 2003
23. The Prescription and Limitation (Scotland) Act 1973
24. The Privacy and Electronic Communications ( EC Directive) Regulations 2003 (no. 2426) and The Privacy and Electronic Communications ( EC Directive) (Amendment) Regulations 2004 (no. 1039)
25. Public Health Legislation in Scotland
26. The Public Interest Disclosure Act 1998
27. The Public Records (Scotland) Act 1937
28. The Radioactive Substances Act 1993
29. The Re-use of Public Sector Information Regulations 2005
OTHER OBLIGATIONS
30. Administrative Law
31. Blood Safety and Quality Legislation
32. The Common Law Duty of Confidentiality
33. Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the Community Code Relating to Medicinal Products for Human Use
RELEVANT STANDARDS AND GUIDELINES
34. BSIPD 0016: Document scanning. Guide to scanning business documents
Find out more here
35. BSIBIP 0008
36. BSIPD 5000
37. BSEN 61010
38. BS 5454:2000
39. BSISO/ IEC 17799:2005 BSISO/ IEC 27001:2005 BS7799-2:2005
40. ISO 15489
41. ISO 19005 - Document Management
42. The NHS Scotland Information Governance Toolkit
Professional Codes of Conduct
43. The General Dental Council, Standards for Dental Professionals (06/05)
44. The General Medical Council
45. Health Professionals Council: Standards for Conduct, Performance and Ethics, (01/03)
46. The Nursing and Midwifery Council Code of Professional Conduct
47. The Chartered Society of Physiotherapy: Rules of Professional Conduct
48. Scottish Social Services Council: Codes of Practice for Social Service Workers and Employers
49. Information on ethical practice
50. Nursing and Midwifery Council ( NMC) Record Keeping Guidance
51. Midwives' Rules and Standards - NMC Standards

ANNEX D - 'THE MANAGEMENT, RETENTION AND DISPOSAL OF PERSONAL HEALTH RECORDS
1. Introduction
2. Interpretation of the Schedule
3. Health Records Retention Schedule
4. Principles to be used in Determining Policy Regarding the Retention and Storage of Essential Maternity Records

ANNEX E - NHSSCOTLAND PERSONAL HEALTH RECORDS MANAGEMENT POLICY FOR NHS BOARDS
1. HEALTH RECORDS MANAGEMENT POLICY
1.1 Introduction
1.2. Scope of the Policy
1.3. Definition of a Health Record
1.4. Aims of Health Records Management System
1.5. Health Records Life Cycle Process
1.6. Legal and Professional Obligations
1.7. Roles and Responsibilities
1.8. Retention and Disposal Schedules
1.9. Health Records Inventory
1.10. Health Records Management Systems Audit
1.12. Health Records Policies and Procedures
1.13. Training
2. DEFINITIONS & ACRONYMS
2.1. Definitions
2.2. Acronyms
2.3. References
A2 - LOCAL RETENTION SCHEDULE FOR HEALTH RECORDS AND DATASETS
A3 - SAMPLE HEALTH RECORDS INVENTORY SURVEY FORM
A4 - INFORMATION GOVERNANCE STANDARDS 3E.2 : PATIENT RECORDS
A5 - HEALTH RECORDS MANAGEMENT IMPROVEMENT PLAN
Sample Action from Health Records Management Improvement Plan
A6 - HEALTH RECORDS POLICIES & PROCEDURES POLICES & PROCEDURES
001. Retention, Destruction and Archiving Of Health Records
002. Confidentiality/Security and the Release and Management of Information
003. Security of Health Records Storage Areas
004. Transportation of Health Records Within and Outwith Organisation Boundaries
005. Electronic Transmission of Patient Identifiable Data
006. Temporary And Duplicate Case records
007. Medical Records Filing Systems
008. Case record Tracking / Tracering
009. Missing Case records
011. Splitting of Voluminous Case record Folders
013. Searching and Updating Patient Demographic Data In The Master Patient Index
015. Filing of Loose Documentation

ANNEX F - NHSSCOTLAND PERSONAL HEALTH RECORDS MANAGEMENT STRATEGY FOR NHS BOARDS
1. Introduction
2. Scope
3. Aims
4. Key Elements
5. National Strategic Direction
6. Review