Records management processes
Implementing and maintaining effective records management depends on the knowledge of what records are held, where they are stored, who manages them, in what format(s) they are made accessible, and their relationship to organisational functions (for example finance, estates, IT, healthcare or social care provision).
An information survey or record audit is essential to meeting this requirement.
This survey will also help to enhance control over the records, and provide valuable data for developing review and disposal policies and procedures.
There should also be audits of the content of clinical records.
The Royal College of Physicians health informatics unit developed an audit tool to support the implementation of the generic medical record-keeping standards.
Regardless of the media on which the records are kept, it is the responsibility of each organisation to ensure that all records are complete, reliable, authentic and available.
In addition, organisations must be satisfied that all records are kept in an accessible format.
The records must:
- provide adequate evidence of the conduct of business to account for a financial transaction including reasons for any decision(s) necessary for that transaction to take place
- contain verifiable evidence that all transactions were appropriately undertaken and where necessary were properly authorised
- provide complete information to document the transactions
- evidence the delivery of care, treatment and services
- comply with regulatory and accountability record-keeping requirements
- be comprehensive and document the complete activity i.e. contain a full audit
Organisations should have in place a process for documenting its records management activities.
Professional Record Keeping Standards, April 2008 provide guidance on the content structure of hospital admission records, handover and discharge communications.
Records should accurately reflect communications, decisions and actions taken to:
- allow employees and their successors to undertake appropriate actions in the context of their responsibilities
- facilitate an audit or examination of the Organisation by anyone so authorised
- protect the legal and other rights of the organisation, its patients, staff and any other people affected by its actions
- provide authentication of the records so that the evidence derived from them is shown to be credible and authoritative
Records should be arranged in a record-keeping system that will enable the Organisation to ensure the quick and easy retrieval of information.
How to register records
Registration is a system which allocates a unique identifier (numerical and alphabetical prefix) to each record and which annotates that sequentially in a ‘register’ or index.
It provides evidence that a record has been created or captured and facilitates retrieval.
Paper and electronic record keeping systems should contain descriptive and technical documentation to enable the system to be operated efficiently and the records held in the system to be understood.
The documentation should provide an administrative context for effective management of the records.
The record keeping system, whether paper or electronic, should include a documented set of rules for classification, titling, indexing and, if appropriate, the protective marking of records.
These should be easily understood to enable the efficient retrieval of information when it is needed and to maintain security and confidentiality.
A coherent file system for all types of records provides for faster and systematic filing, faster retrieval of information, greater protection of information and increased administrative stability, continuity, efficiency and public accountability.
Systems need to provide complete and accurate information on all transactions which occur in relation to a particular record including:
- protective markings
- changes in description, contents etc
- activity levels
- pattern and duration of use
The Northern Ireland Records Management Standard (NIRMS) - Filing Systems, gives guidance on the types of paper based systems.
An effective filing system has a classification method which reflects and supports the organisation’s business functions and activities.
Registration must ensure:
- the file title is unique
- the reference identity assigned to each file is unique and must include the year of opening as an element
- that both are relevant to and easily understood by all users
- each element should relate to a different hierarchical level of the file title
- the details are recorded on the file cover and the register
At a minimum the file description must identify:
- its title
- its unique identifier
- the date it was registered (opened)
- the date it is due to be closed and reviewed, destroyed or arrangements made to transfer to PRONI
Accurate file titling is essential for an efficient filing system.
The title of every file should:
- accurately reflect its contents
- be as specific as possible
- indicate both the information content and the types of documents e.g. ‘Personnel Committee – agenda and minutes’ rather than just Personnel Committee
If titles are inaccurate, ambiguous or imprecise retrieval of information will be difficult.
Staff time will be wasted, staff will lose confidence in the system, leading to an increase in the duplication of files and the creation of unregistered files.
A structural approach to the titling of files relating to the functional areas of the Organisation or subject matter is recommended.
Titles should be meaningful. Words like ‘general’ (which indicates you do not know what it should be) or ‘miscellaneous’ (which indicates you cannot be bothered to think about it) should not be used.
All abbreviations or acronyms should be spelt out in full.
Types of files
Case files contain different types of documents which all relate to one individual person or matter e.g.
- employee files in personnel departments
- supplier files in a purchasing department
- patient files in a hospital or community setting
- client files in a day centre or community setting
Files not directly related to a patient/client/family/carer are routine registered files sometimes known as policy files.
Organisations must agree all registered file covers with PRONI and should incorporate the boxes shown below.
The file cover should always record the year the file was opened and if it has been closed it should record the year it was closed.
The cover should also record the date of the first paper; the date of the last paper and where appropriate the continuation number or former file number.
The date of closure will determine the date of the First and Second Review.
The retention period is normally calculated from the date the file is closed.
In some cases this will differ but full details are given in Part 2 of GMGR.