Scottish Government Records Management: NHS Code of Practice (Scotland) Version 2.0

ANNEX B - RESOURCES TO SUPPORT IMPROVEMENT

The Role of the Information Governance Framework and the Information Governance Toolkit

Information Governance is defined as:-

"A framework for handling information in a confidential and secure manner to appropriate ethical and quality standards in a modern health service".

It is the information component of Clinical Governance and it aims to support the provision of high quality care to patients and clients and service users by promoting the effective and appropriate use of personal, sensitive information.

The Information Governance Framework enables NHS Boards and staff working within them, to ensure that personal information is dealt with legally, securely, effectively and efficiently. The focus is on setting standards and giving NHS Boards the tools to help them to incrementally achieve the defined requirements and make appropriate improvements to their service, which is sustained.

The Information Governance Framework addresses the following key areas when handling information:

• Caldicott recommendations on the use of patient identifiable information;
• NHS Scotland Confidentiality Code of Practice;
• Data Protection Act 1998;
• Freedom of Information (Scotland) Act 2002;
• Information Management and Technology Security ( ISO 17799 Code of Practice for Information Security Management);
• Health and Corporate Records Management;
• Information Quality Assurance.

The Information Governance Framework also enables the NHS to monitor and manage change by educating staff, developing codes of practice, helping organisations and individuals to understand the requirements of law and ethics in respect of information handling and the consequent need for changes to systems and processes. Furthermore, it enables the NHS to work in partnership with patients and clients by respecting their preferences and choices and addressing their concerns about the use of sensitive, personal information. The Information Governance Toolkit provides the means by which NHS Boards can assess their compliance against the national information governance standards. The standards can be viewed here

The Standards in the toolkit explain and expand upon those published in the NHSQIS Clinical Governance and Risk Management Standards, which were published in October 2005. For further information please visit here

The reports produced by the toolkit will be shared with NHSQIS as part of the Clinical Governance and Risk Managements Standards peer review visits.

The Department of Health has published 'Setting and Achieving the NHS Standards for Record Management - A Roadmap'. The roadmap applies to England only, but may be of interest to a Scottish audience as it contains a range of practical tools and guidance, including a knowledge base and templates that have been designed to support organisations in the implementation of the principles contained in the English version of the NHS Records Management Code of Practice.

The content of the Roadmap will be reviewed and updated at regular intervals. The Roadmap is available electronically to all organisations here

Other Reference Material

Good Practice Guidelines for General Practice Electronic Patient Records

' SCIMP Good Practice Guidelines for General Practice Electronic Patient Records' for Scottish guidance on the transfer of electronic health records.

Quality and Outcomes Framework ( QOF)

The Primary Medical Services (Scotland) Act 2004 introduced the concept of the Quality and Outcomes Framework ( QOF) as a voluntary contractual requirement for participating GP practices. The QOF provides a significant financial incentive to demonstrate achievement against a wide range of clinical and organisational quality standards.

Confidentiality and Disclosure of Information: General Medical Services

The Scottish Guidance NHS Circular: PCA(M)(2005)10 'Confidentiality and Disclosure of Information: General Medical Services ( GMS), Section 17c Agreements, and Health Board Primary Medical Services ( HBPMS) Code of Practice and Directions' sets out guidance on the confidentiality of information held by contractors - referred to collectively in this document as "contractors" - who provide General Medical Services ( GMS), Section 17C Agreements and Health Board Primary Medical Services ( HBPMS). Find out more here

Code of Practice on Records Management - Section 61 of Freedom of Information (Scotland)Act

The Scottish Ministers 'Code of Practice on Records Management' under Section 61 of the Freedom of Information (Scotland) Act 2002. Find out more here

The Code of Practice provides guidance to all public authorities as to the practice which it would, in the opinion of the Scottish ministers, be desirable for them to follow in connection with the management of records under the Freedom of Information (Scotland) Act 2002.

Records Management: NHS Code of Practice (Department of Health)

The Records Management: NHS Code of Practice, on which this guidance is based, was published by the Department of Health as guidance to NHS organisations in England on 30 March 2006. Find it here

The National Archives of Scotland: Model Action Plan for Developing Records Management

The National Archives of Scotland: Model Action Plan for Developing Records Management Arrangements Compliant with the Code of Practice on Records Management under Section 61 of the Freedom of Information (Scotland) Act 2002 can be found here

A records management action plan detailing the steps that health service organisations should take to reach the standards set out in the Scottish Ministers' Code of Practice.

The National Archives of Scotland: Developing a Policy for Managing Email

'The National Archives Guidelines on developing a policy for managing e-mail can be found here

The Royal College of Pathologists: The retention and storage of pathological records and specimens (4th edition, 2009 )

The document contains guidance from The Royal College of Pathologists and the Institute of Biomedical Science regarding the management of pathology records.

Recommendations for the retention of pharmacy records (2008)

Guidance on retention periods for pharmacy records can be obtained from the Royal Pharmaceutical Society.

Information Commissioner : CCTV Code of Practice

The Code of Practice provides guidance and advice for CCTV users on how to comply with the Data Protection Act and also includes a simple checklist for users of very limited CCTV systems where the full provisions of the code would be too detailed.. This code is available here

Information Commissioner: The Use and Disclosure of Health Data

Find this document here

Information Commissioner : How does the Data Protection Act Apply to Recording and Retaining Professional Opinions

This good practice note aims to inform organisations and practitioners about some of the data protection issues that arise in relation to the information about individuals that they record in their professional opinions here

Active Records Management: Records Creation

A document that provides advice and guidance on the creation of paper-based files, it does not cover the creation of electronic files. It deals with the creation of registered files including policy, administrative and case files but not staff personal files. Find out more here

e-Government Technical Standards

There are a number of Government standards which aim to ensure the consistency of electronic information transferred between public organisations or made available to the public through means such as websites. e- GIF is mandatory for all public sector bodies, including the NHS. Full details can be found here

Health and Social Care Data Standards

The National Clinical Dataset Development Programme was established by the Chief Medical Officer in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-Health Strategy.

Further information can be obtained from their website here and the standards are published in the Health and Social Care Data Dictionary here

Health Rights Information Scotland ( HRIS)

HRIS provide clear accurate and up to date information about health rights. This includes information about what patients can expect from the NHS, accessing health records and being involved about decisions about their health care. Full details of publications can be found here

University of Edinburgh Records Management Section

Access their site here

University of Edinburgh file naming conventions

This document has been prepared as part of the Policy and Planning Records Management Project and is aimed primarily at people working within Academic Affairs, Planning and Secretariat departments in higher education. However, the principles will be beneficial to all staff working with corporate records including staff in NHS organisations. Find out more here

Scanning and Document Management in General Practice (May 2006)

SCIMP have produced this simple guide to implementing the single scanning and document management system that has now been procured for Scottish General Practices.

Healthcare Information Governance Post-Graduate Education Programme

Unit 2 focuses on Records Management

Information Governance in NHS Scotland: a competency framework

Provides a foundation for the development, commissioning and review of information governance related education and training. The Framework is a set of national competencies describing what healthcare staff should know and be able to do in relation to information governance. The competences are arranged in five 'domains' (holding, obtaining, recording, using and sharing information) and four levels ('Foundation' to 'Advanced'). This approach will enable managers and training providers to tailor learning to the particular needs of staff groups.

Useful Contacts

Scottish NHS Archives and The National Archives of Scotland

There are at present three NHS archivists providing archive services to NHS Boards in Scotland. They can provide advice on the selection and preservation of healthcare records and the management of current records.

Mike Barfoot

Tel: 0131 650 3392
E-mail: lhsa@ed.ac.uk

Alistair Tough

Tel: 0141 330 2992 or 0141 287 2883
Fax: 0141 330 4158
E-mail: A.tough@Archives.gla.ac.uk

Fiona Watson

Tel: 01224 555562
E-mail: f.watson@nhs.net

For advice on archiving in the NHS Tayside area contact:

Pat Whatley

Tel: 01382 344095
E-mail: p.e.whatley@dundee.ac.uk

Alternatively, the National Archives of Scotland ( NAS) can provide advice about records management and archives. NAS does not offer an archive facility to local NHS boards and organisations, but can suggest appropriate archive contacts elsewhere:

Tel: 0131 535 1314
E-mail: enquiries@nas.gov.uk

The National Archives of the United Kingdom( TNA) published a 'Code of Practice for Archivists and Records Managers under Section 51(4) of the Data Protection Act 1998' (Oct 2007). Chapter 3 summarises the particular responsibilities of records managers in relation to personal data. Archival advice about moving images can be obtained from:

Tel: 0845 300 7300

Scottish Government eHealth Directorate

Tel: 0141 242 0426
E-mail: robert.bryden@scotland.gsi.gov.uk
Tel: 0131 244 2351
E-mail: kim.kingan@scotland.gsi.gov.uk

Information Commissioner - Scotland Office

(Data Protection Act 1998)

Telephone: 0131 301 5071
Email: Scotland@ico.gsi.gov.uk
Website: http://www.ico.gov.uk/

Scottish Information Commissioner

(Freedom of Information (Scotland) Act 2002)

Tel: 01334 464610
Fax: 01334 464611
E-mail: enquiries@itspublicknowledge.info
Website: www.itspublicknowledge.info

NHSScotland Information Governance Programme

Tel: 0131 275 7867
Email: NSS.infogov@nhs.net
Website: www.elib.scot.nhs.uk/infogov