Scottish Government Records Management: NHS Code of Practice (Scotland) Version 2.0

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. The guidance has subsequently been reviewed and updated following the recommendations contained within the Strathmartine Report published in 2008 and requests from the service to incorporate the guidance and retention schedules for both Health Records and Administrative Records in to a single document.

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 and administrative 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 following types of NHS records are covered by this retention schedule (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, 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).

Annex D applies to personal health records and annex E to administrative records.

Please note:

• sections 1, 2, 3, annex D and E are for implementation;
• annexes A, B and C are to aid understanding and provide reference to other useful information;