NHS Records Management
Guidance for access to health records requests
This guidance aims to assists NHS organisations in England, through the process of dealing with an access request in accordance with the relevant legislation and any subsequent considerations. The guidance covers legislation pertinent to accessing health records, such as:
- Data Protection Act 1998
- Access to Health Records Act 1990
- Freedom of Information Act 2000
- Access to Medical Reports Act 1988
A clinicians' guide to record standards - Gateway reference number: 10508
The Royal College of Physicians (RCP) in partnership with us has developed standards for hospital patient records, approved by the Academy of Medical Royal Colleges. The standards will improve patient safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.
Please visit the RCP website for further details: http://www.rcplondon.ac.uk/projects/generic-standards-clinical-records
The standards are accompanied by a two-part clinicians' guide:
- Part 1 - provides the background and context of the development of the RCP Health Informatics Unit's professional record keeping standards for the structure and content of medical records. Specifically the generic medical record keeping standards and the standards for admission, handover and discharge records.
- Part 2 - includes the generic medical record keeping standards, and provides the standard headings and definitions of the hospital admission records, and handover and discharge communications.
Hard copies of both parts can be ordered via the Department of Health Publications Online page. You will need to register before ordering.
Please visit: http://www.orderline.dh.gov.uk/ecom_dh/public/home.jsf
Records Management Roadmap
The Records Management Roadmap contains a range of practical tools and guidance designed to support organisations in the implementation of an effective records management system in line with the principles contained in the Records Management: NHS Code of Practice.
The Roadmap comprises 'how to' materials in the form of templates and checklists to assist organisations in developing and implementing solid records management processes. It complements the guidance and knowledge-based materials in the Information Governance Toolkit.
The Roadmap is in electronic format only, available via this website, enabling speedy updates to be made when new material is produced. The release of the Roadmap will be phased. The current content includes guidance on:
- An Approach to Records Management Audit v1.0 (PDF, 165Kb)
- A Model Records Management Policy (Word, 103Kb)
- A Model Records Management Strategy (Word, 168Kb)
- A Records Inventory Survey Template (Word, 76Kb)
- Electronic records inventory form definitions (Word, 64Kb)
- Electronic records inventory survey form (Excel, 160Kb)
- Manual records inventory form definitions (Word, 68Kb)
- Manual records inventory survey form (Excel, 72Kb)
- Raising the profile of records management - 'Getting Started' (Word, 155Kb)
- The Roadmap Framework v1.3 (PDF, 207Kb)
Records Management: NHS Code of Practice
Visit NHS Codes of Practice and legal obligations for the 'Records Management: NHS Code of Practice'.
The following records management modules are available in the IG Training Tool
- Records Management and the NHS Code of Practice - Foundation
- Records Management in the NHS - Practitioner
- Access to Health Records - Practitioner
- The importance of good clinical record keeping - Introductory
- Record keeping standards for hospital inpatients - Foundation
To view the speaker notes for the presentations (PPT files) whilst online, open the file, right click on the first slide, then in PowerPoint 2002 select "Speaker Notes", in PowerPoint 2003 select "Edit Slides".
- Corporate Records Management: Practitioner level training presentation (PPT 365Kb)
- Health Records Management: Foundation level training presentation (PPT 141Kb)
- Health Records Management: Practitioner level training presentation (PPT 266Kb)
- Outline Records Management training modules v1.0 (PDF 13Kb)
- Records Management and the NHS Code of Practice: Foundation level training presentation (PPT 912Kb)
Other guidance material may be added later.