Information Governance Records Management Guidance Note Number 007: Health Records Policies and Procedures Polices and Procedures

There is a policy for the retention, destruction or archiving of health records in accordance with national guidelines. The method of destruction must ensure that confidentiality is maintained at all times.

001

PRIMAP Standard 4 (Point 4.9)

There is a policy on confidentiality and the release and management of information that complies with the relevant legislation and national guidance. The policy sets out how the organisation ensures that information held about patients, their families and staff is managed confidentially.

002

PRIMAP Standard 4 (Point 4.17)

IG Standard 6.005

There is a policy for ensuring the physical security of areas where health records may be accessed e.g. locking doors; filing cabinets etc.

003

PRIMAP Standard 4 (Point 4.21)

There is a policy in respect of safe and secure transportation of health records within and without the organisation's boundaries.

004

PRIMAP Standard 4 (Point 4.28)

IG Standard 5.001

There is a policy in respect of receipt and transmission of faxes and electronic data flows containing confidential patient identifiable information.

005

PRIMAP Standard 4 (Point 4.31)

There is a policy for the creation and subsequent incorporation of temporary records.

006

PRIMAP Standard 4 (Point 4.38)

There is a protocol for safe manual and object handling practices that all staff are fully aware of.

PRIMAP Standard 2 (Point 2.11)

Refer to NHS Boards' Moving and Handling Procedures

There is a mechanism to ensure that all equipment used in the department conforms to the appropriate legislation.

PRIMAP Standard 2 (Point 2.14)

Refer to NHS Boards' Estates Procedure for Equipment checks

There are procedures for the safe storage and retrieval of health records both manual and electronic

007

PRIMAP Standard 2 (Point 2.27)

There are procedures for booking records out from the normal filing system, which enables rapid retrieval of records and prevents misfiling.

008

009

PRIMAP Standard 2 (Point 2.28)

There is a method for indicating alert to risk factors, which is used consistently in all patient records, with the case note containing a designated place for healthcare professionals to record actual allergies/risks; to be signed and dated.

010

PRIMAP Standard 3 (Point 3.4)

Please note policy 010 has not been drafted as it was felt this would be best developed at local hospital or NHS Board level.

There is a procedure for splitting fat folders, including cross-referencing of the volumes, such that clinical staff may efficiently use them.

011

PRIMAP Standard 3 (Point 3.10)

There is a procedure relating to the return of patient-held records to the health records department when the episode of care for an individual patient is complete.

012

PRIMAP Standard 3 (Point 3.11)

Please note policy 010 has not been drafted as it was felt this would be best developed at local hospital or NHS Board level.

There is a procedure for issuing local patient identifiers. The relevant staff are aware of the procedure and there is evidence of implementation.

013

PRIMAP Standard 4 (Point 4.10)

There is a procedure for updating patient demographic details ( e.g. change of address) when these are notified to a member of the organisation's staff.

013

PRIMAP Standard 4 (Point 4.12)

There is a procedure for handling subject access requests, with clear responsibility for responding by fully trained and resourced staff who process such requests efficiently and in accordance with the law.

014

PRIMAP Standard 4 (Point 4.18)

Please note policy has not been drafted as it was felt this would be best developed at local hospital or NHS Board level.

There is a procedure in place which identifies the responsibility for filing of loose documentation within case records. This makes reference to the responsibility of all stakeholders.

015

PRIMAP Standard 3 (Point 3.15)