Publication - Advice and guidance

Scottish Government Records Management: NHS Code Of Practice (Scotland) Version 2.1 January 2012

Published: 11 Jan 2012
Part of:
Health and social care
ISBN:
9781780455471

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

Scottish Government Records Management: NHS Code Of Practice (Scotland) Version 2.1 January 2012
ANNEX A - GLOSSARY OF RECORDS MANAGEMENT TERMS

ANNEX A - GLOSSARY OF RECORDS MANAGEMENT TERMS

Note: The National Archives of the United Kingdom publishes standards, guidance and toolkits on the management of public records in all formats. These standards reflect the legislative and administrative arrangements, which apply to UK public records. However, in so far as they are applicable to Scotland, they contain helpful practical advice, which is commended to Scottish public authorities.

A

Access

The availability of, or permission to consult, records. (The National Archives, Records Management Standard RMS1.1)

Appraisal

The process of evaluating an organisation's activities to determine which records should be kept, and for how long, to meet the needs of the organisation, the requirements of Government accountability and the expectations of researchers and other users of the records. (The National Archives, Records Management Standard RMS 1.1)

Archives

Those records that are appraised as having permanent value for evidence of ongoing rights or obligations, for historical or statistical research or as part of the corporate memory of the organisation. Those records that are appraised as having permanent value. (The National Archives, Records Management Standard RMS 3.1)

Authenticity

An authentic record is one that can be proven:

  • To be what it purports to be;
  • To have been created or sent by the person purported to have created or sent it; and
  • To have been created or sent at the time purported.

To ensure the authenticity of records, organisations should implement and document policies and procedures which control the creation, receipt, transmission, maintenance and disposition of records to ensure that records creators are authorised and identified and that records are protected against unauthorised addition, deletion, alteration, use and concealment. (BS ISO 15489-1:2001(E))

B - C

CHI Number

The CHI ('Community Health Index') number is a unique numeric identifier, allocated to each patient on first registration with the system. It is a 10-character code consisting of the 6-digit date of birth ( DDMMYY), two digits, a 9th digit, which is always even for females and odd for males, and an arithmetical check digit. It is a key component in the implementation of an Electronic Patient Record in Scotland.

Classification

The systematic identification and arrangement of business activities and/or records into categories according to logically structured conventions, methods and procedural rules represented in a classification system. (BS ISO 15489-1:2001(E))

Conversion (See Also Migration)

The process of changing records from one medium to another, or from one format to another. (BS ISO 15489-1:2001(E))

Corporate Records

Records (other than health records) that are of, or relating to, an organisation's business activities covering all the functions, processes, activities and transactions of the organisation and of its employees.

Current Records

Current records are those records necessary for conducting the current and on-going business of an organisation.

D

Destruction

The process of eliminating or deleting records beyond any possible reconstruction. (BS ISO 15489-1.2001(E))

Disposal

Disposal is the implementation of appraisal and review decisions. These comprise the destruction of records and the transfer of custody of records (including the transfer of selected records to an archive institution). They may also include the movement of records from one system to another (for example, paper to electronic). (The National Archives, Records Management Standard RMS1.1)

Disposition

A range of processes associated with implementing records retention, destruction or transfer decisions which are documented in disposition authorities or other instruments. (BS ISO 15489- 1:2001(E))

E

Electronic Record Management System

A system that manages electronic records throughout their lifecycle, from creation and capture through to their disposal or permanent retention, and retains their integrity and authenticity while ensuring that they remain accessible.

F - G

File

An organised unit of documents grouped together either for current use by the creator or in the process of archival arrangement, because they relate to the same subject, activity or transaction. A file is usually the basic unit within a records series.

An accumulation of records maintained in a predetermined physical arrangement. Used primarily in reference to current records. (The National Archives, Records Management Standard RMS 1.1)

Filing System

A plan for organising records so that they can be found when needed. (The National Archives, Records Management Standard RMS 1.1)

H

Health Record

Health records are the most important tool to support patient care and continuity of that care. The health record is a single record with a unique identifier, which is a composite of all data on a given patient held by an organisation. It contains information relating to the physical or mental health of an individual who can be identified from that information and which has been recorded by, or on behalf of, a health professional, in connection with the care of that individual. This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the on-going care of the patient to which it refers.

I

Indexing

The process of establishing access points to facilitate retrieval of records and/or information. (BS ISO 15489-1:2001(E))

Information Audit

An information audit looks at the means by which an information survey will be carried out and what the survey is intended to capture.

Information Survey/Records Audit

An information survey or records audit is the comprehensive gathering of information about records created or processed by an organisation. It helps an organisation to promote control over its records, and provides valuable data for developing records appraisal and disposal procedures. It will also help an organisation to:

  • Identify where and when records are generated and stored within the organisation and how they are ultimately disposed of;
  • Accurately chart the current situation in respect of records storage and retention organisation-wide, to make recommendations on the way forward and the resource implications to meet existing and future demands of the records management function.

Integrity of Records

The integrity of a record refers to its being complete and unaltered. It is necessary that a record be protected against unauthorised alteration. Records management policies and procedures should specify what additions or annotations may be made to a record after it is created, under what circumstances additions or annotations may be authorised and who is authorised to take them. Any unauthorised annotation, addition or deletion to a record should be explicitly indicated and traceable.

J

Jointly Held Records

Where a record is jointly held by health and social care professionals, e.g. in an Integrated Health and Social Care Community Mental Health Team ( CMHT), it should be retained for the longest period for that type of record. That is, if social care has a longer retention period than health, the record should be held for the longer period.

K - M

Metadata

Contextual information about a record. Data describing context, content and structure of records and their management through time. Metadata is structured information that enables us to describe, locate, control and manage other information. Metadata can be broadly defined as "data about data". Metadata is defined in ISO 15489 as: data describing context, content and structure of records and their management through time. It refers to the searchable definitional data that provides information about or documentation of other data managed within an application or environment. For example, a library catalogue, which contains data about the nature and location of a book, is data about the data in the book.

Therefore, metadata should include (amongst other details) elements such as the title, subject and description of a record, the creator and any contributors, the date and format. For further information, see The National Archives: Metadata Standard here

The e-Government Metadata Standard (e- GMS) lays down the elements refinements and encoding schemes to be used by government officers when creating metadata for their information systems. The e- GMS forms part of the e-Government Information Framework (e- GIF). The e- GMS is required to ensure maximum consistency of metadata across public sector organisations. Find out more here

Microform

Records in the form of microfilm or microfiche, including aperture cards.

Migration (See Also Conversion)

The act of moving records from one system to another, while maintaining the records' authenticity, integrity, reliability and usability. (BS ISO 15489-1:2001(E))

Minutes (Master Copies)

Master copies are the copies held by the secretariat of the meeting, i.e. the person or department who actually takes the minutes, writes them and issues them.

Minutes (Reference Copies)

Copies of minutes held by individual attendees at a given meeting.

N

NHS Records

All NHS organisations are public authorities under Schedule 1 of the Freedom of Information (Scotland) Act 2002. The records created and used by all NHS employees are subject to the terms of the Public Records (Scotland) Act 2011. The information contained in those records is subject to Data Protection and Freedom of Information legislation.

O- P

Paper Records

Records in the form of files, volumes, folders, bundles, maps, plans, charts, etc.

Permanent Retention

Corporate and health records will not normally be retained for longer than the specified retention period. However a selection of records of long-term legal, administrative, epidemiological and/or historical value should be identified for permanent preservation. Such records should be transferred to an archive, either the organisation's own NHS archive or a local authority, university, or other archive with which the organisation has an existing relationship.

Section 33 of the Data Protection Act permits personal data identified as being of historical or statistical research value to be kept indefinitely as archives.

Preservation

Processes and operations involved in ensuring the technical and intellectual survival of authentic records through time. (BS ISO 15489-1:2001(E))

Protective Marking

The Protective Marking System (often referred to as the Government Protective Marking System/Scheme or GPMS) is the Government's administrative system to ensure that access to information and other assets is correctly managed and safeguarded to an agreed and proportionate level throughout their lifecycle, including creation, storage, transmission and destruction.

Publication Scheme

A publication scheme is required of all NHS organisations under the Freedom of Information (Scotland) Act. It details information, which is available to the public now or will be in the future where it can be obtained from and the format it is available in. Schemes must be approved by the Scottish Information Commissioner and should be reviewed periodically to make sure they are accurate and up to date.

Public Records (Scotland) Act 2011

The Act's purpose is to improve records management in named Scottish public authorities, including NHS Boards. It aims to do this by making it compulsory to produce and maintain Records Management Plans, updating the definition of 'public records', setting up the Keeper's role in compliance monitoring and guidance provisions, and updating the law on records of the Scottish courts.

R

Records

Information created, received and maintained as evidence and information by an organisation or person, in pursuance of legal obligations, or in the transaction of business. (BS ISO 15489.1) An NHS record is anything, which contains information (in any medium) which has been created or gathered as a result of any aspect of the work of NHS employees - including consultants, agency or casual staff.

Records Management

Field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records, including processes for capturing and maintaining evidence of and information about business activities and transactions in the form of records. (BS ISO 15489-1:2001(E))

Records Management Plan (defined in the Public Records (Scotland) Act 2011

Part 1 of the Public Records (Scotland) Act 2011 imposes duties on certain public authorities such as NHS Boards to produce, implement and review records management plans.

  • o The Plan must set out the arrangements for the management of records created or held by the NHS Board and records created or held by contractors who carry out any functions on behalf of the Board.
  • o Each Plan must identify a coherent governance structure, and list the processes and procedures the Board will undertake to ensure effective management, storage and disposal of records
  • o Each Plan must be submitted to the Keeper of the Records of Scotland for agreement and, once implemented, be kept under internal review
  • o Boards must have due regard to the model plan and the guidance issued by the Keeper when preparing their own plans.

Record Series

Documents arranged in accordance with a filing system or maintained as a unit because they result from the same accumulation or filing process, or the same activity; have a particular form; or because of some other relationship arising out of their creation, receipt or use. (International Council on Archives' ( ICA) General International Standard Archival Description or ISAD(G). Find out more here

Record System/Record-Keeping System

An information system which captures, manages and provides access to records through time. (The National Archives, Records Management: Standards and Guidance - Introduction Standards for the Management of Government Records). Records created by the organisation should be arranged in a record-keeping system that will enable the organisation to obtain the maximum benefit from the quick and easy retrieval of information. Paper and electronic record-keeping systems should contain descriptive and technical documentation to enable the system and the records to be understood and to be operated efficiently, and to provide an administrative context for effective management of the records. The record-keeping system, whether paper or electronic, should include a documented set of rules for referencing, titling, indexing and, if appropriate, the protective marking of records. These should be easily understood to enable the efficient retrieval of information and to maintain security and confidentiality.

Redaction

The process of removing, withholding or hiding parts of a record, for example in a Subject Access Request where parts of the health record refers to third-party information. The National Archives provides guidance on redaction, available here

Registration

Registration is the act of giving a record a unique identifier on its entry into a record-keeping system.

Retention

The continued storage and maintenance of records for as long as they are required by the creating or holding organisation until their disposal, according to their administrative, legal, financial and historical evaluation.

Review

The examination of records to determine whether they should be destroyed, retained for a further period, or transferred to an archive.

S

Scottish Information Commissioner (See Also UK Information Commissioner)

The Scottish Information Commissioner enforces and promotes the right to access information held by public authorities, created by the Freedom of Information (Scotland) Act 2002 and the Environmental Information (Scotland) Regulations 2004, both of which came into force on 1 January 2005. The Act and the Regulations give anyone, anywhere inthe world, important rights to access the information held by more than 10,000 public authorities in Scotland.

Scottish NHS Archivists

Three NHS Boards in Scotland employ archivists: Grampian (which also provides an archive service to NHS Highland), Lothian, and Glasgow. The funding and managerial arrangements for each of these archives differs, but each collects, lists and preserves corporate and health records of and relating to the NHS organisations and predecessor bodies and institutions in their local area. NHS organisations which do not employ their own Archivist are welcome to contact one of the NHS Archivists for advice and information on records management and archiving. These organisations may wish to make their own arrangements with local authority, university or other archives for the transfer of records selected for permanent preservation; such arrangements require the agreement of the Keeper of the Records of Scotland.

The Health Archives and Records Group ( HARG) is a representative body for archivists and records managers working in the health sector, including but not limited to the NHS. Its membership is drawn from across the UK and the Republic of Ireland. It has been an affiliated group of the Society of Archivists' Specialist Repositories Group since 2001. HARG aims to raise the profile of health archives and to improve the level of awareness in the NHS and elsewhere about record-keeping issues.

T

Tracking

Creating, capturing and maintaining information about the movement and use of records. (BS ISO 15489-1:2001(E))

Transfer Of Records

Transfer (custody) - Change of custody, ownership and/or responsibility for records. (BS ISO 15489-1:2001(E))

Transfer (movement) - Moving records from one location to another. (BS ISO 15489-1:2001(E))

U - Z

UK Information Commissioner (See Also Scottish Information Commissioner)

The UK Information Commissioner enforces and oversees the Data Protection Act 1998 in the UK and liaises with the Scottish Information Commissioner with regards to the interaction between the Data Protection Act 1998 and the Freedom of Information (Scotland) Act 2002.

Weeding

The process of removing inactive/non-current records from the active/current or primary records storage area to a designated secondary storage area after a locally agreed timescale after the date of last entry in the record.

In an archiving sense, weeding can also mean the removal of records during appraisal which are not suitable for permanent retention and should be destroyed.