record keeping in health and social care

WebRecording is an integral and important part of social work and social care. records of patients treated by NHS organisations, records of patients treated on behalf of the NHS in the private healthcare sector, records of private patients treated on NHS premises, records created by providers contracted to deliver NHS services (for example, GP services), adult service user records who receive social care support, records held as part of a Shared Care Records programme, records held by local authorities such as public health records, contraceptive and sexual health service records, corporate records - administrative records relating to all functions of the organisation, registers - for example, birth, death, Accident and Emergency, theatre, minor operations, administrative records, for example, personnel, estates, financial and accounting records, notes associated with complaint-handling, X-ray and imaging reports, output and images, secondary uses records (such as records that relate to uses beyond individual care), for example, records used for service management, planning, research, physical records (records made of physical material such as plaster, gypsum and alginate moulds), audio and video tapes, cassettes, CD-ROM etc, text messages (SMS) and social media (both outgoing from the NHS and incoming responses from the patient or service user) such as Twitter and Skype, metadata added to, or automatically created by, digital systems when in use - content can sometimes be of little value if it is not accompanied by relevant metadata, websites and intranet sites that provide key information to patients or service users and staff, outline the role of records management within the organisation and its relationship to the organisations overall strategy, define roles and responsibilities within the organisation in relation to records, including the responsibility of individuals to document their actions and decisions - an example is, who is responsible for the disposal of records, assign responsibility for the arrangements for records appraisal, selection and transfer for the permanent preservation of records (as required by section 3 (1) of the Public Records Act 1958), provide a framework for supporting standards, procedures and guidelines and regulatory requirements (such as CQC and the Data Security and Protection Toolkit), indicate the way in which compliance with the policy and its supporting standards, procedures and guidelines will be monitored and maintained, provide the mandate for final disposal of all information by naming the committee or group that oversees the processes and procedures, provide instruction on meeting the records management requirements of the FOIA and the UK GDPR, what series of records it holds (and potential quantities), the business area that created the record (and potential Information Asset Owner), professional de-registration: temporary suspension or permanent, regulatory intervention: leading to conditions being imposed upon an organisation, or monetary penalty issued by the ICO, creation: create and log quality information, retention: keep or maintain in line with NHS recommended retention schedule, appraisal: determine whether records are worthy of archival preservation, disposal: dispose appropriately according to policy, identify strategies to satisfy requirement, sufficient metadata to allow it to remain reliable, integral and usable (refer to section 3), links between other documents that form part of the transaction the record relates to, a record with web links that do not work once they are converted to another format, loses integrity, a record with attachments, such as hyperlinks or embedded documents that do not migrate to newer media, are not complete or integral, an email message that is not stored with the other records related to the transaction, is not integral as there are no supporting records to give it context, paper records can deteriorate over time - so can digital media as the magnetic binary code can de-magnetise in a process called "bit rot" leading to unreadable or altered information, thus reducing its authenticity, software upgrades can leave other applications unusable as they may no longer run on updated operating systems, media used for storage may become obsolete or degrade, and the technology required to read them may not be commercially available, file formats become obsolete over time as more efficient and advanced ones are developed, migration to the new systems (retaining existing formats - this is the preferred method), emulation (using software to simulate the original application), conversion to a standard file format (or a limited number of formats), specification of a policy that lays down a consistent approach to digital records, detailed planning against typical (and actual) case scenarios, identification of (internal or external) resources that can be deployed as part of those plans, identification of where and how the associated digital evidence can be gathered that will support case investigation, a process of continuous improvement that learns from experience, there is a full inventory of what is held offsite, retention periods are applied to each record, there is evidence of secure disposal of records and information. Where clinical information is being processed by the public health function it is expected to comply with the Code of Practice for Confidential Information. Retention begins at the end of the year to which they relate. The principles of good record keeping in the Republic Review and destroy if no longer required Good quality records underpin safe, effective, compassionate, high-quality care. Local publicity campaign involving signage and poster and local communications or advertising. Review and consider transfer to PoD This practice is ok to continue if this is what currently occurs. Recorded conversations: which may be needed later for clinical negligence or other legal purposes* If records are arranged in an organised filing system, such as a business classification scheme, or all the relevant information is placed on the patient or client file, providing records as evidence will be much easier. Other information about a birth must be recorded in the care record. Where multiple teams are involved in the complaint handling, all the associated records must be brought together to form a single record. In any other case, for at least 5 years. GP patient records: de-registered cases where the reason is unknown Recorded conversations: which form part of the health record* It is a best practice benchmark for all organisations creating or holding public records and provides advice and guidance on the tracking of records at all stages of the information lifecycle up to disposal. Retention begins at the CLOSE of the financial year to which they relate. Where there is little impact upon those receiving care, it may be sufficient to use posters and leaflets to inform people about the change, but more significant changes will require individual communications. These specific records may have historical value, so discussions should take place with your local PoD. It has been proven that adequate case take keeping enhanced the quality of treatment. A full dataset is available from ONS. Integrated Care Boards (ICBs) require access to health and care information to determine a patient or service users entitlement to CHC (once the ICB has been notified of this potential entitlement). Reports or statements on these records may be required as evidence in a court of law, and the records management process must facilitate this. Review and consider transfer to PoD Family records used to be common within health visiting teams, amongst others, where a whole family view was needed to deliver care. In most cases, the supplier of the product or system will be a processor as the product facilitates access to the information held by health and care organisations. Copy or summary of entire record of current caseload.Former provider retains the original record. Record Retention - Illinois Chiropractic Society Organisations may want to keep final reports for longer than the raw data and analysis, for trend analysis over time. Review and if no longer needed destroy, Occupational health report of staff member under health surveillance where they have been subject to radiation doses Review and consider transfer to PoD Organisations may be asked for evidence to demonstrate they operate a satisfactory records management regime. The standard sets out 25 metadata elements, which are designed to form the basis for the description of all information. Event and Transaction Record A scan of not less than 300 dots per inch (or 118 dots per centimetre) as a minimum is recommended for most records although this may drop if clear printed text is being scanned. Yet a different image for a similar case may need to be kept for longer due to the nature of that particular case. Local health and care organisations should have a policy on the use of BYOD by staff. Communications The FOIA was designed to create transparency in government and allow any citizen to know about the provision of public services through the right to submit a request for information. 2 years A designated member of staff of appropriate seniority, ideally with suitable records management qualifications, should have lead responsibility for records management within the organisation. When looking to scan records, organisations need to consider the following: The legal admissibility of scanned records, as with any digital information, is determined by how it can be shown that it is an authentic record. Review and transfer to PoD Finance With no specific timeframe listed in Illinois law; all facets of law must be considered when determining how See Care Quality Commission guidance on controlled drugs. Staff Records and Occupational Health

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