New NHS records management guidance was introduced over the summer. Chris Alderson, one of Hempsons’ information law specialists, provides an overview of the changes.
Every clinical professional realises the importance of recording accurate information on patients and ensuring that is available to others involved in their care. But when that episode of care is finished, NHS organisations still have an obligation to keep records securely. Not doing so can mean information is not available when a patient next needs care – or when there is a complaint or a court case about their care.
New guidance from the Department of Health on records management – both health records and business records – was issued last summer. It introduces some significant changes NHS organisations should be aware of and implement. Records Management: NHS Code of Practice was withdrawn and replaced by the Information Governance Alliance’s Records Management Code of Practice for Health and Social Care 2016. This is now the guidance that all NHS trusts should follow.
The new code of practice is a rather less turgid document than the previous guidance replacing 206 pages with 80. Much of the reduction in length has resulted from the removal of what had been annex C of the previous code (an extensive reference guide to legal and professional obligations) and the introduction of a new classification of records under the retention schedule.
Where the previous retention schedule had only two categories (Health Records and Business and Corporate (Non-Health) Records), the new code identifies 15 separate categories of records. Not only does this assist in locating the relevant retention periods, duplicated guidance and illogical distinctions between records have been removed. For example, the previous code provided for a retention period for all ambulance clinical records of 10 years. The new code makes no separate distinction for such separate ambulance records, and so the retention periods to be used are the standard periods for either adult health records or children’s records, depending on the age of the patient concerned.
The new code of practice also reflects the changes in the way care is now delivered. As the title implies, the guidance now extends to cover adult social care records given the growth in joint care working. The changes in how NHS services are provided are also reflected in new guidance addressing the transfer of records with a change in provider specifically, including where
services are now provided by a non- NHS provider.
While the previous guidance treated electronic records as something of an afterthought, the new code is designed with the particular issues relating to electronic records at its core. There is a significant expansion in the code’s coverage of how records should be managed, including closer linkage to the ISO standards concerning the structure of records and the use of metadata to assist the management and location of information. The guidance has also been updated to reflect changes in the law, including
the reduced statutory period for retention, which is now 20 years under the Public Records Act 1958.
For those working within the complex field of NHS records management, the new code of practice better reflects the reality of how records are used within the NHS and the particular challenges arising from this. For those outside records management
departments, the new code will need to be taken into account and steps taken to ensure that the standards in the code of practice are met.
Key points:
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Trusts need to be aware of changes to guidance on records management
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Electronic records are at the heart of the new guidance
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