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Good Records Management and Data Quality

Good Records Management and Data Quality. Gina Kelly, Health Records Manager. What is Records Management?. Systematic management of all records Paper and electronic records. What is a record?. Records document each and every activity. They are the organisation’s memory.

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Good Records Management and Data Quality

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  1. Good Records Management and Data Quality Gina Kelly, Health Records Manager

  2. What is Records Management? • Systematic management of all records • Paper and electronic records

  3. What is a record? Records document each and every activity They are the organisation’s memory

  4. Types of Records • Health records • X-rays • Administrative records • Photographs, slides, and other images • Microfilm • Audio and video tapes, cassettes, CD-ROM • Diaries • E-mails, text messages • Etc, etc, etc

  5. Who is responsible for records? ‘All individuals who work for an NHS organisation are responsible for any records which they create or use in the performance of their duties….. any record that an individual creates is a public record.’ Records Management: NHS Code of Practice There are therefore INDIVIDUAL, STATUTORY & MANAGERIAL responsibilities for all NHS records, including Health Records

  6. The Records Management: NHS Code of Practice A guide to: • Standards of best practice • Legal requirements

  7. Guidance aims • Establish a Records Management framework • Clarify legal obligations • Detail required actions • Explain the requirement for permanent preservation • Set out recommended minimum retention periods • Where to find further information

  8. Records are a valuable resource! They support: • Patient care • Legal requirements • Clinical audits • Research

  9. Legislation Data Protection ActFreedom of Information Act Caldicott Guidelines

  10. Create Use Retention Appraisal Disposal Record Lifecycle Any record created by an individual, up to its disposal, is a public record and subject to Information Requests Close Record Be aware Monitor Control

  11. Standards linked to Records • NHS Litigation Authority (was CNST) • A set of standards to minimise risk for the organisation, healthcare professionals and service users. • Information Governance A set of standards that govern the way the organisation holds, obtains, records, uses and shares information

  12. Standards continued …. • Information Governance Toolkit - a framework that all NHS organisations must adhere to in order to provide assurance of policies, systems and processes in place to meet the standards • Information Governance Training e-learning mandatory training modules - all staff are required to complete the on-line mandatory module annually.

  13. National Record keeping standards Trusts must audit these standards across all services to meet IG and NHS LA Service user and client records should:- • Be factual, consistent and accurate • Be written in black indelible ink (biro) • Be written or keyed as soon as possible after an event has occurred

  14. National Record Keeping Standards • Be written clearly, legibly and in such a manner they cannot be erased. Staff must not use text language to enter data onto systems. • Abbreviations kept to a minimum • Written wherever possible with service user or carer involvement and terms they will be able to understand • Be consecutive • Bound and stored so that loss of documents minimised.

  15. National Record Keeping Standards Be relevant and useful • Identify problems and action taken to rectify • Provide evidence of care planned, decisions made, care delivered and information shared • Provide evidence of actions agreed with service user (including consent to treatment or consent to share)

  16. National Record Keeping standards And Include: • Clinical observations, examinations, tests diagnoses, prognoses, prescriptions and other treatments • Relevant disclosures by the service user – pertinent to understanding cause or effecting treatment • Facts presented to service user • Correspondence from service user or other parties

  17. National Record Keeping Standards • Records should not include:- • Unnecessary abbreviations, jargon, meaningless phrases • Personal opinions should be restricted to professional judgement on clinical matters • Name/names of third parties involved in serious incident • Correspondence generated from complaints or legal papers

  18. Data Quality • Local drivers • Data Quality quarterly reports sent to CBUs • Payment by Results (PbR)

  19. THE FUTURE • Mersey Care NHS Trust - voice recognition - digital dictation - digital pens • NHS Connecting for Health • National Care Record Service • Choose & Book • PACS • Electronic Prescribing

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