SECTION 1 - FOREWORD
1. The Records Management: NHS Code of Practice, version 2.0, was published by the Scottish Government in August 2010, as a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in Scotland.
2. This document is a refreshed version for 2011. It is based on current legal requirements and professional best practice.
3. The original guidance was drafted in collaboration with a working group made up of representatives from the Scottish Government, Scottish NHS archivists, NHS Health Records Managers, patient groups and GP Practices. It has subsequently been reviewed and updated following the recommendations contained within the Strathmartine Report published in 2008, requests from the service to incorporate the guidance and retention schedules for both Health Records and Administrative Records in to a single document, and feedback received from the service since publication.
4. This 2011 update takes into account the Public Records (Scotland) Act 2011, which seeks to improve records management across Scottish public authorities, including NHS Boards. This revised code offers guidance that is well aligned with the aims of this legislation.
5. The Healthcare Quality Strategy for NHSScotland puts people at the heart of everything the health service does. Through the implementation of the strategy, people will be encouraged to be partners in their own care and can expect a culture of continuous improvement within the NHS. Going forward, the effectiveness and safety of care and the efficient management of healthcare services depends on the right information being available to the right people at the right time. This Code provides a key component of the information governance arrangements that are necessary to support this significant culture change.
6. The aims of this NHS Code of Practice are to:
- establish, as part of the Information Assurance Strategy, records management best practice in relation to the creation, use, storage, management and disposal of NHS records;
- provide information on the general legal obligations that apply to NHS records;
- set out recommendations for best practice to assist in fulfilling these obligations, for example adhering to National Information Governance Standards;
- explain the requirement to select records for permanent preservation;
- set out recommended minimum periods for retention of NHS personal health records and administrative records, regardless of the media on which they are held; and
- indicate where further information on records management may be found.
7. This is an evolving document because standards and practice covered by the Code will change over time. It will therefore be subject to regular review and updated as necessary, with the next review scheduled for 2012, once the implications of the Public Records (Scotland) Act 2011 are fully understood.
Types of Record covered by the Code of Practice
8. The following types of NHS records are covered by this Code of Practice (including records of NHS patients treated on behalf of the NHS in the private health sector) regardless of the media on which they are held, including paper, electronic, still and video images, and sound:
- personal health records (paper based or electronic including those concerning all specialties, and GP medical records);
- records of private patients seen on NHS premises;
- records of blood and tissue donors;
- accident & emergency, birth, and all other registers;
- theatre registers & minor operations (and other related);
- x-ray and imaging reports, output and images;
- administrative records (including, for example, general, financial, property, environmental, health and safety, human resource, procurement/stores, NHS Board and service planning records).