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Records Management

Records management concentrates on both health records and corporate records.  Records are a valuable resource because of the information they contain.  High quality information underpins the delivery of high quality evidence based health care.  An effective records management service ensures that information is properly managed and is available when needed.

The Records Management: NHS Code of Practice sets out best practice guidance for the management of both health and corporate records.  It also sets includes recommeded minimum time periods records should be kept for.  Click below to view.

Records Management: NHS Code of Practice - Part 1
Records Management: NHS Code of Practice - Part 2

Health Records Management

A health record is any record whether on computer or paper which contains information about your physical or mental health condition and is made by or on behalf of health professional involved with your care. Your health record contains:

Personal information, for example, your name, address, date of birth, NHS number Clinical history including inpatient and / or outpatient activity Details of procedures Details of drug administration Investigation reports Outcome of medical treatment Therapy and social work reports
 

Everybody who inputs information into your case note in the Trust has a responsibility for it and must ensure the following:

  • All personal information is accurate and complete - staff must check your personal details such as name, address, gp, date of birth etc when you attend hospital
  • All documentation must be filed within the appropriate section and in the correct order
  • Records are requested and sent around the Trust in a timely manner
  • Records are dealt with in a confidential manner at all times

Records are tracked and therefore can be identified by an audit trail. 

Corporate Records Management

With the introduction of the Freedom of Information Act 2000, corporate records management has become increasingly important.  The Trust needs to know the documents they hold, the purpose foir holding records, how records are stored, how long records are kept for and how records are destroyed.  The benefits of good corporate records management ensures that the Trust is a more open and transparent organisation.

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