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

007. Medical Records Filing Systems

1. Opening Statement

The prime purpose of a Health Records Department is to bring together 3 key players - the patient, the doctor / healthcare professional and the case record i.e. have the right case records in the right place at the right time. Whichever filing system is used, it is imperative that case records are filed accurately as a great deal of time can be wasted searching for mis-filed records. Failure to produce the case record can result in:

• past medical history being unavailable;
• refusal/delay by Consultant to see patient;
• cancellation of procedure;
• distress to patient/relative;
• increase in clinical risk.

2. Filing System

Describe local filing procedure for each records collection, e.g. terminal digit, alphabetical etc.

3. Case records Storage Systems

Describe the various storage systems in use throughout the Board including secondary storage/off- site storage and other media.

4. Electronic Patient Records

Describe local procedures for accessing /indexing documentation and retrieval of records.

Definition of Terms & Acronyms

Reference (National/local guidelines, standards and legislation)

Links (related policies and guidance) can also include web links if applicable

Policy 008 : Case record Tracking / Tracering

Policy 002 : Confidentiality/Security and the Release and Management of Information

Policy 001: Retention, Destruction and Archiving of Health Records Local Moving & Handling policy