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SECTION 1 - FOREWORD
Background
1. The Records Management: NHS Code of Practice has been published by the Scottish Government eHealth Directorate 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. It is based on current legal requirements and professional best practice.
2. The guidance was drafted in collaboration with a working group made up of representatives from the Scottish Government Health Directorate, Scottish NHS archivists, NHS Health Records Managers, patient groups and GP Practices. As part of its work, the working group commissioned a public consultation on the retention and disposal of health records in 2005. The results of that consultation have informed the drafting of this guidance. The draft was updated and issued for consultation during Autumn 2007. Further information can be found here.
3. Scotland's Clinical Governance and Risk Management standards are underpinned by information governance standards, to which Boards are supported in compliance by an electronic toolkit and knowledge portal. These standards make clear to Boards the requirements to be met on the management of patient and administrative records and freedom of information and data protection obligations, amongst other things. This Code provides a key component of these information governance arrangements. Further information regarding the National Information Governance standards relating to Health Records can be viewed via the Information Governance Specialist E-Library here. 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.
Aims
4. The aims of this NHS Code of Practice are to:
- establish, as part of the wider information governance framework, 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 regardless of the media on which they are held, and;
- indicate where further information on records management may be found;
Types of Record covered by the Code of Practice
5. The guidelines contained in Section 1, 2 and 3 and Annex A, B and C of this Code of Practice apply to NHS records of all types (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:
- personal health records (electronic or paper based; 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) registers;
- x-ray and imaging reports, output and images;
- photographs, slides, and other images;
- microform ( i.e. fiche / film);
- audio and video tapes, cassettes, CD- ROM etc;
- e-mails;
- computerised records;
- scanned records;
- text messages (both out-going from the NHS and in-coming responses from the patient);
Annex D, E and F apply to Personal Health Records only.
This is illustrated in the diagram on the below:
Please note:
- sections 1, 2, 3 and annex D are for implementation;
- annexes A, B and C are to aid understanding and provide reference to other useful information;
- annex E and F were produced by a sub-group of the Health Records Forum and are included as guidance on best practice to Health Boards on the development of local health record strategy and policies.
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