Scottish Government Records Management

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SCOTTISHGOVERNMENTRECORDSMANAGEMENTHEALTH AND SOCIAL(SCOTLAND) 2020CARECODEOFPRACTICEA guide to the required standards of practice in the management ofrecords for those who work within or under contract to NHSorganisations in Scotland.The Scottish Government, Edinburgh 2020

Crown copyright 2020You may re-use this information (excluding logos and images) free of charge in anyformat or medium, under the terms of the Open Government Licence. To view thislicence, visit ment-licence/or e-mail: DHCIG@gov.scotWhere we have identified any third-party copyright information you will need to obtainpermission from the copyright holders concerned.This document is available from the Scottish Government Health and CareInformation Governance website at https://www.informationgovernance.scot.nhs.uk/The Scottish GovernmentSt Andrew’s HouseEdinburghEH1 3DGProduced by the Scottish Government supported by the National NHS ScotlandRecords Management Group.Published by the Scottish Government, June 20202

DOCUMENT CONTROL SHEETTitle:Records Management: Health and Social Care Code of PracticeDate Issued:18th May 2020Effective From:1 June 2020Version/IssueNumber:202006Document Type: Code of PracticeDocumentstatus:ActiveAuthor:Scottish Government lead Short Life Working Group for the RMCoP reviewContacts:Elena Beratarbide, IG Policy Lead, Information Assurance &Governance Team, NHS Scotland, Health and Social CareDHCIG@gov.scotTracy Gill, Chair NHSScotland Records Management Group.Owner:Scottish Government, Digital Health and Care DirectorateContact:DHCIG@gov.scottTarget Audience Records Managers, Information Governance Leads, DataProtection Officers, Caldicott Guardians, Senior Information RiskOwners – with responsibility to cascade to all staffSupersedesScottish Government Records Management: NHS Code ofPractice (Scotland) Version 2.1 January 2012Distribution list : open access to this document is available via the NHS ScotlandIG website publications: https://www.informationgovernance.scot.nhs.uk3

Contents1.11.21.31.4ForewordBackgroundStrategic ContextAimsTypes of Records Covered by the Code of Practice2.12.22.3IntroductionGeneral ContextRegulatory Framework: Legal and Professional ObligationsSocial Care Records111113143.13.23.3Roles and ResponsibilitiesRolesTrainingPolicy and Strategy15151717NHS Records Management and Information Lifecycle4.1Records Creation4.2Managing Records4.3Records Maintenance - Storage and Scanning4.4Records Inventory/Information Asset Register4.5Records Management Systems Audit4.6Disclosure and Transfer of Records4.7Retention and Disposal Arrangements4.8Appraisal of Records4.9Records Closure4.10 Records Disposal4.11 Records Security and Business Continuity5.15.25.35.45.55.65.75.85.95.10Useful GuidanceAdopted Persons Health RecordsAmbulance Service RecordsNHS 24 RecordsAsylum Seeker RecordsChild School Health RecordsComplaints RecordsControlled Drugs RegimeData Processors, Subcontractors and Changes in ContractsDeceased PersonDigital Records5.10.1 Management of Metadata5.10.2 Naming Conventions5.10.3 Information Asset Registers5.10.4 Version Control for Electronic Records5.10.5 Format on Dates5.10.6 Access 0313132343435353535364

235.245.255.265.275.10.7 Disposal Management365.10.8 Email Management365.10.9 Duplication of Electronic Data375.10.10 Distributed Records375.10.11 Transient Records385.10.12 Ownership of Electronic Records385.10.13 Social Media Records385.10.14 Scanned Records385.10.15 Cloud-Based Records395.10.16 E-Disclosure of Evidence (parties in litigation)395.10.17 BYOD (Bring Your Own Device) Records395.10.18 Websites and Intranet39Duplicate Records40Family Records40General Practitioner Records41Human Fertilisation41Integrated Records42Long Term Conditions (LTC)43Mental Health Records43Occupational Health Records44Oncology Records44Patient/Client Held Records45Prison, Youth Offenders & Secure Units (Mental) Health records45Records Dealt with Under the NHS Trusts and Primary Care Trusts(Sexually Transmitted Disease) Directions 200046Specimens and Samples46Staff Records46Transgender Persons Health Records47Witness Protection Health Records48Further Guidance, Websites and Links49The Management, Retention and Disposal of Personal Health Records506.16.26.36.46.56.6Scope of ScheduleResponsibilities and Decision MakingRetention PeriodsDisposal and Destruction of Personal Health Records6.4.1 Decision Making6.4.2 Disposal and DestructionInterpretation of the ScheduleHealth Records Retention Schedule6.6.1 Core Retention Periods6.6.2 Specialty Records Retention Periods6.6.3 Pathology (sub-categories)6.6.4 Births, Deaths & Adoption Records6.6.5 Clinical Trials & Research6.6.6 Cross-specialty records5051515252535457585964656668The Management, Retention and Disposal of Administrative Records 74Administrative Records765

CommunicationsCorporate GovernanceEstates and FacilitiesFinancial ManagementHuman ResourcesInformation & Communication TechnologyAnnex A: Acknowledgments76788488939698Annex B: Standard Setting Bodies100Annex C: Glossary of Records Management Terms1026

Foreword1.1Background1The Records Management: NHS Code of Practice, version 2.1, was publishedby the Scottish Government in January 2012, as a guide to the requiredstandards of practice in the management of records for those who work withinor under contract to NHS organisations in Scotland.2This document is a refreshed version for a wider setting including Health andSocial Care. It is based on current legal requirements and professional bestpractice.3This guidance has been drafted by the Scottish Government in collaborationwith representatives of the Scottish Health and Social Care setting, includingrecords managers, archivists and information governance experts from theNHS, Local Authorities and GP Practices.4This 2019 update specifically takes into account the Public Records (Scotland)Act 2011, the Public Bodies (Joint Working) (Scotland) Act 2014, the Childrenand Young People (Scotland) Act 2014, the Multi Agency Public ProtectionArrangements (MAPPA), the Health Board Provision of Healthcare in Prisons(Scotland) Directions and recommendations for Records Management from keyrecent public inquiries, particularly the Scottish (Historical) Child Abuse Inquiry(2015). This review also takes in the requirements of recent changes to thefollowing:5 Data Protection legislation1, NHSS Information Security Policy Framework (2018 and 2019) 2 and the extended powers of the Information Commissioner’s Office (ICO)3,It’s recognised that the culture within the health and social care context ischanging as a result of greater service integration driven by the Digital Healthand Care Strategy 2018. Together with the natural evolution towards a digitalpaper lite environment, and the use of portals for health and social care groups,clinicians and patients. This Records Management for Health and Social Care1 General Data Protection Regulation (EU) 2016/679 (“GDPR”)2 Scottish Government and 2019 Framework 2018 Information Security Policy Framework and 2019Framework3 Information Commissioner’s Officer (ICO)7

Code of Practice 2019 (from this point onwards referred to as the Code ofPractice) is a guide to the practice of managing records. It is relevant toorganisations who work within, or under contract to NHS organisations inScotland. This also includes public health functions in Local Authorities andSocial Care where there is joint care provided within the NHS.6This Code of Practice forms part of a series of information governance andsecurity guidance, including those published by the Scottish Government, andconsulted with the following organisations: British Medical Association (BMA); General Medical Council (GMC); Information Commissioner’s Office (ICO)1.24Strategic Context7The Digital Health and Care Strategy 2018 is ambitious; to create a digital andinteroperable health and social care system, supporting improvement in safety,effectiveness, efficiency and citizen-centred nature of the services we offer.48The strategy focuses on digital innovations for which this Code of Practice playsan important role; this Code of Practice is a guide on how to manage thoserecords within such technologies to enable communication, integrate care,enhance availability of information and better working practices.9This Code of Practice is one of many actions brought forward from the NHSSInformation Security Policy Framework 2015/17 to ensure the confidentiality,integrity and availability of NHSS information and that it is processed in a fairand lawful manner.10Information and communication technologies are important to the progress andthe ambitions set out in The Healthcare Quality Strategy for NHS Scotland 2010to actively support and enable quality improvements in healthcare servicesacross Scotland.11In this strategic context, the Code of Practice is key to ensure a comprehensiveNHS health and social care record is available at the point of need in Scotland.The success of this will depend on many factors, some of them out with thiscode of practice. Other workstreams from the Digital Health and Care Strategy2018, and good records management will be essential to ensure paper andelectronic records are managed consistently.Scotland’s Digital Health & Care Strategy 20188

1.312131.41415AimsThis Code of Practice aims to: establish records management best practice in relation to the creation,use, storage, management and disposal of NHS records (including, whereappropriate, the archival preservation of NHS records); provide information on the general legal obligations that apply to NHSrecords; set out recommendations for best practice to assist in fulfilling theseobligations, for example adhering to national information governance andsecurity standards; set out recommended periods of retention for NHS personal healthrecords and administrative records and social care records held by NHSBoards, regardless of the media on which they are held; and indicate where further information on records management may be found; explain the requirement to select, and transfer to an archive service, thoserecords for archival preservation.This is an evolving document because standards and practice covered by theCode of Practice will change over time. It will be subject to regular reviews andupdated as necessary, with the next review scheduled for 2021.Types of Records Covered by the Code of PracticeThis Code of Practice applies to NHS records in any format (e.g. paper,electronic, microfilm, audio, SMS, etc.), including those handled by third partieson behalf of the NHS either in connection with health and social care, corporateor administrative purposes. Record formats include: E-mails social media (social media includes blogs, wikis and social networks, forexample Twitter, Facebook and Skype) website content (internet or intranet) voice recordingA record is “information created, received, and maintained as evidence andinformation by an organisation or person, in pursuance of legal obligations or in9

the transaction of business”. (ISO 15489-1:2016 Information and documentation Records management .5) This definition extends to the archive role, particularly inrecording corporate memory.16A health record consists of information relating to the physical or mental healthor condition of an individual and has been made by or on behalf of a healthprofessional in connection with the care of that individual.17The following are examples of records covered by this Code of Practice:185 personal health records (paper based or electronic including thoseconcerning all specialties, and GP medical records); records of clinical trials; records of private patients seen on NHS premises; records of blood and tissue donors; accident and emergency, birth, and all other registers; theatre registers and minor operations (and other related); x-ray and imaging reports, output and images, film/video; administrative records (including, for example, staff, complaints, financial,property, environmental, health and safety, human resource,procurement/stores, NHS Board and service planning records). Alsoincludes data processed for purposes other than direct care (secondarypurposes), including planning and management of services and research; health records shared with or transferred to other services (e.g. prisons,integrated health and social services, education and public protectionagencies)Any organisation that processes NHS data under the Scottish Health and SocialCare Integration Scheme should use this Code of Practice, includingsubcontractors processing data on behalf Public Bodies in ue ics/catalogue detail ics.htm?csnumber 6254210

Introduction192.1This Code of Practice draws on advice and published guidance available fromthe Scottish Government Freedom of Information Unit and the National Recordsof Scotland, and from best practice followed by a wide range of organisationsin both the public and private sectors. The guidelines provide a framework forconsistent and effective records management that is standards-based and fullyintegrated with other key information governance and security workstreams.General Context20Effective records management supports operational efficiency by reducing thetime taken to identify and locate information, minimising duplication of recordsand confusion over version control, and offering significant savings in physicaland electronic space.21All NHS organisations, Local Authorities and Integrated Joint Boards involvedin either health or social care, are public authorities under Schedule 1 of theFreedom of Information (Scotland) Act 2002 (FOISA), and the records theycreate are subject to the Public Records (Scotland) Act 2011 (PRSA). Theseorganisations and the Scottish Ministers are obliged under Data Protection,Freedom of Information, and the Environmental Information Regulations, tomake arrangements for the safe keeping and eventual disposal includingtransfer to an archive of all types of records. This Code of Practice is based onthe Scottish Government's understanding of the relevant law in Scotland, at thedate of publication. It is not and should not be read as a statement of thedefinitive legal position on any matter. NHS organisations should consult theirown legal advisors for advice on any legal issues that arise regarding thematters covered in this Code of Practice.22Where a local authority is in partnership with an NHS Board in Scotland for theprovision of Integrated Health and Social Care services, the local authority mustmanage the associated Health and Social Care public records in accordancewith the requirement to make proper arrangements under Section 53 of theLocal Government etc. (Scotland) Act 1994.23Organisations that are not bound by the PRSA or the Local Government etc(Scotland) Act 1994 may have a contractual requirement to manage records onbehalf of the NHS, a local authority or an Integrated Joint Board (e.g. as part ofan NHS Standard Contract).24FOISA and the Data Protection Act (DPA) 2018 have guidance on recordsmanagement practice that recommend the systems and policies that must bein place to comply with the law.11

25Organisations have a common law duty of confidence to patients andemployees as well as a duty to maintain professional ethical standards ofconfidentiality. This duty of confidence continues after an employee orcontractor has left the NHS. Obligations around confidentiality remain even afterthe death of a patient.26Other legislation requires information to be held as proof of an activity againstthe eventuality of a claim (e.g. Limitation Act 1980 or the Consumer ProtectionAct 1987).27Records are a valuable resource because of the information they contain. Highquality information underpins the delivery of first-class evidence-based healthand social care, accountability, clinical and corporate governance and manyother key service deliverables. Information has most value when it is accurate,up to date and accessible when it is needed. An effective records managementservice ensures that information is properly managed and is available wheneverand wherever there is a justified need for information, and in whatever media itis held: support integrated health and social care; support day to day business which underpins the delivery of care; support evidence-based clinical and social care practice; support sound administrative and managerial decision making, as part ofthe knowledge base for health and social care services; meet legal requirements, including requests from patients and customers orother individuals made through provisions of FOISA or Data Protectionlegislations; assist clinical and other audits; support improvements in health and social care effectiveness throughresearch; support archival functions by taking account of the historical importance ofmaterial and the needs of future research; 28support patient choice and control over treatment and services designedaround them.This Code of Practice, together with the supporting Annexes, identifies thespecific actions, managerial responsibilities, and recommended retentionperiods (in line with the 5th principle of the Data Protection Principles in the12

GDPR) for the effective management of all NHS records from creation, as wellas day-to-day use of the record, storage, maintenance and ultimate disposal.292.2All individuals who work for an NHS organisation or local authority areresponsible for any records that they create or use in the performance of theirduties.Regulatory Framework: Legal and Professional Obligations30The principal legislation governing the management of records is PRSA. TheAct places an obligation on public authorities to prepare and implement arecords management plan which sets out proper arrangements for themanagement of their records.31Any record that an individual creates is subject to PRSA, and the informationcontained in such records is subject to FOISA and Environmental Information(Scotland) Regulations 2004 (EIR). There is a specific requirement underRegulation 4 on a public authority to take reasonable steps to organise andkeep up to date environmental information relevant to its functions. The GDPRand DPA 2018 are the principal legislations governing how organisationsprocess and handle personal identifiable information. They set in law howpersonal and special category personal information may be processed.The data processing principles are:a. processed lawfully, fairly and in a transparent manner;b. collected for specified, explicit and legitimate purposes;c. adequate, relevant and limited to what is necessary;d. accurate and where necessary, kept up to date; every reasonable stepmust be taken to ensure that personal data that is inaccurate, havingregard to the purposes for which they are processed, are erased orrectified without delay;e. kept in a form which permits identification of data subjects for no longerthan is necessary for the purposes for which the personal data isprocessed;f. processed in a manner that ensures appropriate security of the personaldata.32FOISA was designed to create transparency in Government and allow anycitizen to know about the provision of public services through the right to submita request for information. This right is only as good as the ability of thoseorganisations to supply information through best practice records management13

programmes. Records managers are required to adhere to a Code of Practiceissued under Section 61 of FOISA.332.3Further information on legal and professional obligations is available on ww.informationgovernance.scot.nhs.ukSocial Care Records34This Code of Practice refers to health and social care records that are held byan NHS Board, including those used in the provision of integrated health andsocial care services. For those health and social care records that are held atlocal authority level, they will fall under the scope the Scottish Council onArchives Record Retention Schedules (SCARRS).35NOTE: Shared social care and authority records should be held for the longestretention period specified in the Code of Practice or SCARRS.14

Roles and Responsibilities36Effective records management enables Health and Social Care organisationsto provide and maintain a high level of service to the public. Adherence to thisCode of Practice will support organisations to act in accordance with legalrequirements, standards, evidence-based practice and professional workpractice.37The records management function should be recognised as a specific corporateresponsibility within every NHS organisation. It should provide a managerialfocus for records of all types in all formats, throughout their lifecycle, fromplanning and creation through to ultimate disposal. It should have clearlydefined responsibilities and objectives, and necessary resources to achievethem.38The NHS Board and the Local Authority are responsible for ensuring theymeet their legal responsibilities.39The Integrated Joint Board is responsible, by delegation of theircorresponding NHS Board and local authority, for ensuring there are suitablearrangements across the integrated services to meet the legal responsibilitiesof the partners, and for the adoption of the agreed governance arrangements.3.1Roles40The Chief Executive of the NHS Board/Local Authority has overallindependent responsibility for records management in their organisation andjoint responsibility across the Health and Social Care Partnership(s). Asaccountable officer they are responsible for the management of theorganisation and for ensuring appropriate mechanisms are in place to supportservice delivery and continuity. This overall responsibility is delegated to theSenior Information Risk Owner (SIRO).41The Senior Information Risk Owner (SIRO) has responsibility for ensuringinformation assets (including records) are processed in a safe, fair and lawfulmanner, regardless of whether the information is processed using digitaltechnologies or not.42The Caldicott Guardian has responsibility for reflecting patients' interestsregarding the use of patient identifiable information. They are responsible forensuring use of patient identifiable information is legal, ethical and appropriate,and that confidentiality is maintained.15

43The Data Protection Officer (DPO) role and responsibilities are defined inSection 4 of the EU General Data Protection Regulation 2016. Article 39 setsout key tasks all DPOs must undertake as part of their role. This includes: informing and advising the controller or the processor, and theiremployees, of their obligations under data protection legislation; monitoring the implementation and application of the organisation’spolicies and training on data (information and records) management aswell as monitoring the application of these policies; providing advice, where required, on data protection impact assessmentsand monitor compliance with this requirement; act as point of contact for the ICO for any matter relating to the dataprotection legislation and to co-operate with the ICO as required; to keep documentation on at least the name of the data flows, the purposeof the processing, the types of subjects and data, the security and privacyrisks and the time limits for data erasure (according to Article 30).Likewise, they must monitor personal data breaches and responses to thesupervisory authority (ICO).44The Health Records Manager is responsible for the overall development andmaintenance of health records management practices throughout theorganisation. They have responsibility for drafting guidance to support goodrecords management practice in relation to health records and for promotingcompliance with this Code of Practice, in such a way as to ensure the efficient,safe, appropriate and timely retention and retrieval of patient information.45The Corporate Records Manager is responsible for the overall developmentand maintenance of corporate and administrative records managementpractices throughout the organisation. They have responsibility for draftingguidance to support good records management practice (other than for healthrecords) and for promoting compliance with this Records Management Code ofPractice.46The Archivists are responsible for collecting, cataloguing, preserving andmanaging appropriate access to valuable historical information. Archivists liaisewith records managers, data protection officers and other informationgovernance professionals to train and identify relevant material of historicalvalue ensuring transfer to archival preservation. Note that valuable historicalinformation may be ‘born digital’ and exist as electronic files as well astraditional paper archives.16

473.2All NHS staff, whether clinical or administrative, who create, receive and usedocuments and records have records management responsibilities. All staffshould ensure that they keep appropriate records of their work and managethose records in keeping with the Code of Practice and the relevant policies andguidance within their Board. NHS managers should demonstrate activeprogress in enabling staff to conform to the Code of Practice, identifyingresource requirements and any related areas where organisational or systemschanges are required.Training48All staff within the NHS Board or its partners involved in handling records onbehalf of the NHS, whether clinical or administrative, should be appropriatelytrained in their records management responsibilities, and are competent tocarry out their designated records management duties. Training should includeboth paper and electronic record formats.49NHS Boards have a duty to ensure the provision of training for staff regardingrecords management in support of their compliance with Element 12 of theirRecords Management plan (RMP), under PRSA. Specific elements should beincluded in training programmes to ensure staff understand appraisal andretention of records.3.3Policy and Strategy50In support of their compliance with Element 3 of their RMP, each NHS Boardshould have in place an overall records management policy statement,endorsed by the Executive Management Team (or its equivalent) and madereadily available to staff at all levels of the NHS Board.51The policy statement should provide a mandate for the performance of allrecords and information management functions. In particular, it should set outan organisation's commitment to create, keep and manage records anddocument its principal activities in this respect.52The policy should also: outline the purpose of records management within the organisation, andits relationship to the organisation's overall strategy; define roles and responsibilities within the organisation including theresponsibility of individual NHS staff to document their actions anddecisions in the organisation's records, and to dispose of recordsappropriately when they are no longer required;17

53 define roles, responsibilities and procedures for safe transfer, storage orconfidential disposal of records when staff leave an organisation, or whenNHS Board premises are being decommissioned; define the process of managing records throughout their lifecycle, fromtheir creation, usage, maintenance and storage to their disposal be itultimate destruction or archival preservation; provide a framework for supporting standards, procedures and guidelines; indicate the way in which compliance with the policy and its supportingstandards, procedures and guidelines will be monitored and maintained.The policy statement should be reviewed at regular intervals (a minimum ofonce every three years or sooner if new legislation, codes of practice or nationalstandards are introduced) and, if appropriate, it should be amended to maintainits relevance.18

NHS Records Management and InformationLifecycle54PRSA requires every authority to prepare a “Records Management Plan”setting out proper arrangements for the management of their public recordsthroughout their lifecycle.55Records (and the information in them) are considered to have a "lifecycle". This“lifecycle” starts at creation or receipt of the record in the organisation andcontinues throughout the period of its 'active' use, then into the period of'inactive' retention (such as closed files which may still be required occasionallyfor reference purposes). The “lifecycle” concludes with either confidentialdisposal or (for a very small proportion) archival preservation in an archivalfacility as designated in the RMP.56A similar "information lifecycle" approach applies to managing the flow of aninformation system's data and associated metadata, from creation and initialstorage to the time when it becomes obsolete and is deleted or retained byarchive.CreationActive useInactiveretentionFinal disposalor PreservationFigure 1 The Information (Records) lifecycle57The ISO 15489:2016 Information and Documentation - Records ManagementStandard focuses on the business principles behind records management andhow organisations can establish a framework to enable a comprehensiverecords management programme.19

58The standard describes the characteristics of a record (authenticity, reliability,integrity and usability). These characteristics allow strategies, policies andprocedures to be established that will enable records to be authentic, reliable,integral and usable throughout their lifecycle.59To ensure that these characteristics are maintained, sufficient persistentmetadata must be attached to each record. It is essential that a recordsmanagement process is designed that will allow records to possess thesecharacteristics.60The industry standard for the design and implementation of recordsmanagement, as given in the ISO standard ISO154

4.11 Records Security and Business Continuity 28 Useful Guidance 29 5.1 Adopted Persons Health Records 29 5.2 Ambulance Service Records 29 5.3 NHS 24 Records 29 5.4 Asylum Seeker Records 30 5.5 Child School Health Records 30 5.6 Complaints Records 30 5.7 Controlled Drugs Regime 31 5.8 Data Processors, Subcontractors and Changes in Contracts 31

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