ARCHIVING POLICY AND PROCEDURE PAPER RECORDS

Version:

FINAL

Ratified by (name of Committee):

Date ratified:

Provider Quality and Safety

Committee/Commissioner Quality
and Patient Safety Assurance
Committee
July 2010

Date issued:

July 2010

Expiry date:
(Document is not valid after this date)
Review date:

June 2013

Lead Executive/Director:

Head of Communications and

Community Engagement
Sandra
Fessey,
Corporate
Services Manager
WPCT employees

Name of originator/author:
Target audience:

March 2012

Version History

Version

Date issued

Issued To

V1.0

23.11.07

V1.1

09.01.08

V1.2

17.01.08

V2

26 June 2008

Quality and Safety

Committee

V2.1

23 March
2010

V2.2

14 April 2010

V2.3

25 May 2010

Jayne Merriman,
Judy Irving, Jannet
Allen, Sandra
Fessey
Records
Management Group
Information
Governance Group

V2.4

02 June 2010

Judy Irving

V2.5

04 Jan. 11

Sandra Fessey

Date of Issue
Location of document

Page 2 of 16

Dave Kendall, Trudi

Wylde, Jayne
Merriman, Tina
Evans, Michael
Whitefoot
Information
Governance Group
Information
Governance Group
Associate Directors
of Provider
Services/Jane Pugh

Brief Summary of
Change
Addition of archiving
procedures for FHS
and Childrens
services

Owners name
Sandra Fessey

Sandra Fessey
Page 6 - Additional
clarification of
guidelines for use by
childrens services.
Changes to Policy list.
Changes to Appendix
V in respect of lifting
of boxes
Formatted to fit with
corporate
requirements.
Monitoring tool to be
added. Impact
assessment to be
added.
Processes updated
following completion
of procurement
process.
P6 clarification of
diaries
P4 and 7 insertion
of IG Policies in policy
lists
Addition of Business
Unit Administrators
Amendment of
contact details

Sandra Fessey

Sandra Fessey

Sandra Fessey

Sandra Fessey
Sandra Fessey

Sandra Fessey
Jannet Allen

Worcestershire Primary Care Trust

Wildwood
Wildwood Drive
Worcester WR5 2LG
27/7/2010
Corporate Services Administrator, Trust
Headquarters
WPCT Archiving Policy and Procedure

CONTENTS

SECTION

PAGES

1.

Background

2.

Purpose and Scope

3.

Roles and Responsibilities

4.

Implementation

5.

Archiving Offsite

6.

Process for Archiving Records Offsite

7.

Retrieval of records from Offsite Storage Facility

8.

Implementation of the Policy

9.

Review/Development of the Policy

10.

Other Relevant Policies and Guidelines

11.

Glossary of Terms

12.

Reference List

Appendix A:
Appendix B:
Appendix C:
Appendix D:
Appendix E:
Appendix F:

Page 3 of 16

Archiving Flow Chart

Retrieval Flow Chart
Archived Record Sheet
How to Fill a Box
Contact Sheet
Equality Impact Assessment

10
11
12
13
14
15

WPCT Archiving Policy and Procedure

1.

Background

On 6 April 2006 the Department of Health published new guidance relating to records
management entitled Records Management: NHS Code of Practice. This Code of
Practice replaces previous guidance as follows:

HSC 1999/053 For the Record

HSC 1998/217 Preservation, retention and destruction of GP general medical
services records relating to patients
HSC 1998/153 Using electronic patient records in hospitals: Legal requirements
and good practice

The above guidance and other information management policies form the basis for this
archiving policy.
This policy should be read in conjunction with NHS Worcestershire other information
management policies and guidelines, namely:

Records Management Policy (including Department of Health Retention & Disposal

Schedules)

Records Management Strategy

Data Protection Policy

Freedom of Information Policy

Access to Health Records Staff Guidelines

Code of Practice for Employees in respect of Confidentiality

Information Governance Policy and Strategy

Staff Paper Diary Policy

2.

Purpose and Scope

The intention of this policy is to provide clear instructions to all Trust staff regarding the
appropriate retention and disposal of paper based records via an agreed archiving
process.
The policy is also intended to aid paper records storage issues identified at various Trust
sites and to eliminate the need to retain paper records unnecessarily.
3.

Roles and Responsibilities

It is the responsibility of all Trust staff to ensure that paper records are filed and archived
correctly all employees have a duty to keep confidential information safe (Data
Protection Act 1998).
The policy relates to all paper filing systems not just those containing patient/client
information.

Page 4 of 16

WPCT Archiving Policy and Procedure

4.

Implementation

In addition to any NHS policies and guidance regarding the maintenance of patient/client
paper records and other filing systems, it is good general office practice to weed out and
destroy, or archive, unnecessary paperwork on a regular basis.
Before any archiving process is implemented, whether on or offsite, all collections of paper
forming a file must be checked for duplicates to ensure that the minimum number of
papers is kept. In addition, only papers considered essential to the file should be kept.
Any duplicates identified must be destroyed in local confidential paper disposal facilities or
by other appropriate confidential methods e.g. shredding.
All remaining papers must be correctly filed according to local policies/procedures. The
file must not contain loose papers unless the file is to be sealed.
Each file must be clearly and appropriately labelled with detail of the file content and
agreed review/destruction date as a minimum. (Refer to the Trusts Records Management
Policy Appendix D: Retention & Disposal Schedule for appropriate destruction date).
In some instances it is usual practice within the Trust for paper files to be archived on the
premises and it is assumed that filing space has been allocated for this purpose for all
closed files that need to be retained. In areas, however, where storage of records is
limited e.g. locality offices and health centres, offsite storage will be required, and it is the
aim of this Policy to guide staff through the process of archiving correctly, particularly in
relation to offsite storage.
5.

Archiving Offsite

Where space is severely limited, it will be necessary to archive paper records away from
the premises. The Trust has therefore arranged for access to an archiving service based
in Worcestershire, which is run by Whitefoot Forward Ltd.
It is extremely important to note that each box of records that is sent to offsite storage has
a cost implication in terms of the cost of processing the box, the cost of storing the box for
the agreed retention period, and the cost of retrieval.
6.

Process for Archiving Records Offsite

In all cases identify the documents that need to be kept in accordance with the NHS
Retention & Disposal Schedule. Remove all duplicates and any unnecessary papers.
Obtain the agreed official archiving boxes and barcode numbers. For how to do this
please refer to your Business Unit Administrator or identified Service Lead for archiving
(see Appendix E). Each Unit will have its own account and any requests/storage fees will
be allocated to that account.

Page 5 of 16

WPCT Archiving Policy and Procedure

Contact Whitefoot Forward Ltd (email: smartstorage@whitefoot-forward.co.uk ) and

request archive boxes and barcodes, minimum order is 20 (boxes come flat-packed).
Your request will need to contain the following information:
Your account number
Authorised requesting contact name (Business Unit/Service Lead)
Delivery method e.g. next day
Address for delivery, opening times and contact telephone number
When commencing your archiving secure papers with treasury tags, or place in
appropriately labelled envelopes. Do not use staples, paper clips, files or rubber bands as
these rust or perish.
When filling your box itemise all the records that you are placing in the box on the
spreadsheet indicated at Appendix C which includes barcode number, patient details,
department and service location, and retention and disposal details. Where records are
not patient orientated give details of the type of record you are archiving.
Do not mix types of records or years. Keep one type of record to one box, eg discharges
in one, and diaries in another.
You will need to identify how long your archived records need to be kept and insert a
disposal date in the spreadsheet. To identify retention and disposal arrangements use the
NHS Retention & Disposal Schedule, which can be found on the Trust intranet at
http://nww.worcestershire.nhs.uk/guidelines--policies--procedures/recordsmanagementarchiving.aspx or the Trust public website attached to the Records
Management Policy found within Corporate Policies at
http://www.worcestershire.nhs.uk/publications/policies-and-procedures/corporate.aspx.
In all cases the box should contain a list of each set of records that is in the box.
Make sure your box is not overfilled or too heavy (see Appendix D). The maximum
weight for Health & Safety purposes is 13 kg. Lie documents flat in the archiving box, as
standing documents upright puts excess strain on the sides of the box and causes it to
become misshapen so the lid will no longer fit, only fill your box up to the handle hole.
Once your box is full and you have put a list of the contents inside the box, use parcel tape
to seal the box by taping around the lid and across the top of the box. Place your barcode
label at the short end of the box where it is printed customer box reference.
When boxes are ready to be collected, contact Whitefoot Forward Ltd by emailing
smartstorage@whitefoot-forward.co.uk quoting your account number and authorised
contact name. Boxes that are not appropriately filled and labelled will be refused
collection by the offsite storage company.
On collection a purchase order work sheet is signed off by Whitefoot Forward and Trust
personnel, and copies retained by both parties. This is then used to validate the payment
invoice.

Page 6 of 16

WPCT Archiving Policy and Procedure

For ease of reference please follow the instructions in the flow chart Quick Steps to
Offsite Storage - attached to this policy at Appendix A. It is recommended that each
work area laminates this flow chart and places it in an appropriately designated area for
referral by staff.
7.

Retrieval of records from the offsite archive storage facility

If the records for retrieval are required urgently, delivery can be arranged for the same
day, or alternatively, the retrieved record can be collected in person (with prior
arrangement). However, bearing in mind the costs involved, retrieval will normally be
delivered via the Whitefoot Forward courier service the next day or specified day of the
week.
To arrange for retrieval contact Whitefoot Forward by email (smartstorage@whitefootforward.co.uk ) quoting the following details:
Your account number and authorised requesting contact name
Box Barcode Number
Delivery method (e.g. next day delivery basis)
Location box to be delivered to
Name and contact details of requestor
Office/clinic manned opening times
Upon receipt of your request Whitefoot Forward Ltd will send a confirmation email with
your reference number. You should keep a note of this number with your request details
as this will need to be quoted if there is any query.
You should receive confirmation within 1 hour, if requested during working hours,
otherwise it will be responded to the following working day. If you have not received
confirmation, then please contact Whitefoot Forward Ltd via telephone (01299 250566) to
ensure they have received the email.
Do not send the request to any email address other than the one listed as there is no
guarantee it will be responded to.
If you are requesting delivery within 1 hour then contact Whitefoot Forward Ltd by
telephone informing them of the request.
For ease of reference please follow the instructions in the flow chart Retrieval of
files/records - attached to this policy at Appendix B. It is recommended that each work
area laminates this flow chart and places it in an appropriately designated area for referral
by staff.
8.

Ordering, Invoicing and Payment

Whitefoot Forward Ltd is aware of the complex structure of the Trust, necessitating the
need for a number of separately identifiable accounts, being consistent with the
specialities and activities managed for each of the Trusts nominated locations.
The Trust will raise a single annual Purchase Order (Call-off) per account, for which
Whitefoot Forward will raise a single monthly invoice per account, detailing the appropriate
itemised charges accordingly.
Page 7 of 16

WPCT Archiving Policy and Procedure

Whitefoot Forward Ltd will forward invoices including details of the Trusts official Purchase
Order numbers to NHS Shared Business Services for processing.
9.

Implementation and dissemination of the Policy

This policy is effective immediately. The policy will be published on the Trust internet and
intranet pages.
10.

Review/Development of the Policy

This Policy will be reviewed every three years, unless circumstances arise that require an
early review or updating of the policy.
11.

Other Relevant Policies and Guidelines

NHS Code of Practice: Records Management

PCT Records Management Policy (including Department of Health Retention & Disposal
Schedules)
PCT Records Management Strategy
PCT Data Protection Policy
PCT Freedom of Information Policy
PCT Access to Health Records Staff Guidelines
PCT Code of Practice for Employees in respect of Confidentiality
PCT Information Governance Policy and Strategy
All the above policies and guidance can be found on the Trusts website at
http://www.worcestershire.nhs.uk/publications/policies-and-procedures/corporate.aspx
12. Glossary of Terms
CONFIDENTIAL INFORMATION
The PCT has a duty under the Data Protection Act to hold, obtain, record, use, and store
all personally identifiable information in a secure and confidential manner. This applies to
all personal identifiable information held in manual files, computer databases, videos and
other automated media about living individuals, such as personnel and payroll records,
medical records, other manual files, microfiche/film, pathology results, x-rays etc
CORPORATE RECORDS
Records (other than health records) that are of, or relating to, an organisations business
activities covering all the functions, processes, activities and transactions of the
organisation and of its employees.
DESTRUCTION
The process of eliminating or deleting records beyond any possible reconstruction.
FILE
An organised unit of documents grouped together either for current use by the creator or in
the process of archival arrangement, because they relate to the same subject, activity or
transaction. A file is usually the basic unit within a records series.

Page 8 of 16

WPCT Archiving Policy and Procedure

FILING SYSTEM
A plan for organising records so that they can be found when needed.
HEALTH RECORD
A single record with a unique identifier containing information relating to the physical or
mental health of a given patient who can be identified from that information and which has
been recorded by, or on behalf of, a health professional, in connection with the care of that
patient. This may comprise text, sound, image and/or paper and must contain sufficient
information to support the diagnosis, justify the treatment and facilitate the ongoing care of
the patient to whom it refers.
NHS NUMBER
Introduced in 1996, the NHS number is a unique 10 character number assigned to every
individual registered with the NHS in England (and Wales).
PAPER RECORDS
Records in the form of files, volumes, folders, bundles, maps, plans, charts, etc.
RECORDS
Information created, received and maintained as evidence and information by an
organisation or person, in pursuance of legal obligations, or in the transaction of business.
An NHS record is anything which contains information (in any media) which has been
created or gathered as a result of any aspect of the work of NHS employees including
consultants, agency or casual staff.
RECORDS MANAGEMENT
Field of management responsible for the efficient and systematic control of the creation,
receipt, maintenance, use and disposition of records, including processes for capturing
and maintaining evidence of and information about business activities and transactions in
the form of records.
RETENTION
The continued storage and maintenance of records for as long as they are required by the
creating or holding organisation until their eventual disposal, according to their
administrative, legal, financial and historical evaluation.
RETRIEVAL
Return of paper records to authorised personnel.
13. Reference List
Department of Health (DoH) Records Management: NHS Code of Practice
DoH Retention and Disposal Schedule
PCT Records Management Policy
Whitefoot Forward Ltds Smart Storage Box Filling Procedure

Page 9 of 16

WPCT Archiving Policy and Procedure

APPENDIX A
ARCHIVING

Quick steps to offsite storage

What do I need to do?

Does the document/file require offsite storage?

NO
File remains in on-site storage

YES
Preparing your files for archiving

Obtain barcode labels and flat-packed boxes from Whitefoot Forward via email:
smartstorage@whitefoot-forward.co.uk (minimum order 20).
In order to do this you will require an account number (insert here when displaying
flowchart) from your Business Unit Administrator or Archiving Service Lead (see
Appendix E).
Your request to Whitefoot Forward must contain account number, authorised contact
name, delivery instructions (eg. next day) and your name, address and telephone
number
Index files using the Archiving Index spreadsheet (Appendix C) and save a copy into
the shared file on the M drive relevant to your own Business Unit.
Fill the box in accordance with Whitefoot Forwards guidance (Appendix D)

Collection of Files

Contact Whitefoot Forward to collect boxes via:

smartstorage@whitefoot-forward.co.uk
Remember to quote your account number and authorised contact name.
Confirm the number of boxes to be collected and arrangements for collection i.e. next
day collection, address and opening times, contact name and telephone number.
On collection a purchase order work sheet is signed off by Whitefoot Forward and PCT
personnel, and copies retained by both parties. The purchase order worksheet is then
used to validate the payment invoice.
Important - please note that only boxes filled in accordance with the Whitefoot Forward
guidance will be collected.

Page 10 of 16

WPCT Archiving Policy and Procedure

APPENDIX B

Retrieval of files/records
Once a file/record is identified for retrieval from the offsite storage, the file
will be recalled by box In order to recall the box you will need the barcode
reference number that you will obtain from your indexing system.

Request the box via Email smartstorage@whitefoot-forward.co.uk

*do not send to any other email as you will not be guaranteed a response*
Quoting:
1. Box barcode number
2. Account Number
3. Delivery method i.e. normal/ next day/1hour
4. Delivery arrangements i.e. manned opening times, delivery point
5. Authorised requesting contact name

Once the request is sent via Email to Whitefoot Forward you will receive a
confirmation email with a work reference number within 1 hour of your request.
Please keep a note of this number as you will be required to quote it if you have any
queries or you wish to follow up your request. If you do not receive confirmation
within 1 hour follow up the request via telephone on 01299 250566.

If requesting an urgent box for delivery within 1 hour contact Whitefoot

Forward via Telephone 01299 250566 again quoting barcode number,
delivery method and authorised contact name.

Whitefoot Forward will process the request and return

the requested box by agreed delivery arrangements.

Page 11 of 16

WPCT Archiving Policy and Procedure

APPENDIX C
ARCHIVED RECORD SHEET

Please complete one sheet per box.

Barcode Number

NHS
Number

Patient
Surname

Patient
date of
birth

Date patient
last
seen/date of
death/type of
record

This is the
date of the
actual record

Page 12 of 16

Directorate
Lead (Job
Title)
Who is the
lead member
Refer to
Refer to
of staff for
DOH
the DOH
your
guidelines Guidelines department

Department/ Department/Service Storage Retention

Service
Location
Location
Period

Your dept

Where you are

based

Where
the box
will be
stored

WPCT Archiving Policy and Procedure

Disposal
Date

APPENDIX D

Page 13 of 16

WPCT Archiving Policy and Procedure

APPENDIX E
AUTHORISED CONTACT SHEET
RECORD
LOCATION
Trust
Headquarters
(Wildwood),
Isaac Maddox
House,
Crossgate
House
Adult
Therapies

RECORD
TYPE
Corporate/
Commissioner
records

CONTACT
PERSON
Corporate
Services
Administrator

CONTACT DETAILS

Patient health
records

Business Unit
Administrator

Tel: 01905 733677 ext 31337

Email: Naomi.seers@worcspct.nhs.uk

Community
Hospitals
Adult Nursing
Childrens
Services

Patient health
records

Business Unit
Administrator

Tel: 01905 733706

Email: Sue.ratheram@worcspct.nhs.uk

Family Health
Services

Prison
Services

Childrens
Business Unit
health records Administrator

FHS records/
Deceased
patient GP
records
Prison health
records

Evesham
Community
Hospital
Tenbury
Community
Hospital

Patient health
records

Princess of
Wales
Community
Hospital
(POWCH)

Patient health
records

Page 14 of 16

Patient health
records

Business
Support
Manager
FHS Manager

Tel: 01905 760016, ext: 37202, Email:

Jannet.Allen@worcestershire.nhs.uk,

Tel: 01905 733677 ext 31337

Email: Naomi.seers@worcspct.nhs.uk
Tel: 01905 681597
Email: Trudi.wylde@worcspct.nhs.uk
Tel: 01905 760149
Email: jayne.merriman@worcspct.nhs.uk

Administrators, Tel: 01527 785037

HMP Hewell
Email: Gail.healing@worcspct.nhs.uk /
ghealing@nhs.net or
Sharon.Prescott1@HMPS.gsi.gov.uk
Medical
Tel: 01386 502431
Records
Email: Julie.Meadows@worcspct.nhs.uk
Manager
Office
Tel: 01584 810643,
Manager
Email:
Jenny.Biddlecombe@worcspct.nhs.uk
Administration
Manager/Site
Manager

Tel: 01527 488332

Email: Jeanette.Mann@worcspct.nhs.uk,

WPCT Archiving Policy and Procedure

Equality Impact Assessment Report

APPENDIX F

Your Equality Impact Assessment Report should demonstrate what you do (or will do) to
make sure that your function/policy is accessible to different people and communities, not
just that it can, in theory, be used by anyone.
1. Name of policy or function
Archiving Policy and Procedure Paper Records
1. Responsible Manager
Sandra Fessey, Corporate Services Manager
2. Date EIA completed
17 June 2010
3. Description of aims of function/policy
The intention of this policy is to provide clear instructions to all Trust staff regarding the
appropriate retention and disposal of paper based records via an agreed archiving
process. The policy is also intended to aid paper records storage issues identified at
various trust sites and to eliminate the need to retain paper records unnecessarily.
4. Brief summary of research and relevant data
Department of Health Records Management NHS Code of Practice
Department of Health Records Management Retention and Disposal Guidelines
PCT Records Management Strategy
PCT Records Management Policy
Clinical Records Management Policy
Information Governance Policies and Procedures
5. Methods and outcomes of consultation
The policy has gone through consultation with the Records Management Group and
Information Governance Steering Group, who have provided views and their comments
have been incorporated into the document. Following the EIA the policy will proceed to
Provider Services Quality and Safety Committee and the Commissioner Quality and
Patient Safety Assurance Committee.
Results of Initial Screening or Full Equality Impact Assessment
Initial or Full Equality
Impact Assessment?
Equality Group
Race
Gender
Disability
Age
Sexual Orientation
Religion or Belief
Page 15 of 16

Assessment of Impact
Low
Low
Low
Low
Low
Low
WPCT Archiving Policy and Procedure

Human Rights

Low

6. Decisions and or recommendations (including supporting rationale)

Not Applicable
7. Equality action plan (if required)
Not Applicable
8. Monitoring and review arrangements (include date of next full review)
The Records Management Steering Group will lead in monitoring the effectiveness of
the Policy and will determine whether the policy needs to be updated before the expiry
date to reflect any new legislation and best practice. Next full review (March 2013) will
be in line with date on the front cover of this policy.
Department
Directorate
Director
Report produced by and
job title
Date report produced
Date report published

Page 16 of 16

Corporate Development
Information Governance
Richard Stringfellow
Sandra Fessey, Corporate Services Manager
17 June 2010
7 July 2010

WPCT Archiving Policy and Procedure