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ARCHIVING POLICY AND PROCEDURE PAPER RECORDS

Version: FINAL

Ratified by (name of Committee): Provider Quality and Safety


Committee/Commissioner Quality
and Patient Safety Assurance
Committee
Date ratified: July 2010

Date issued: July 2010

Expiry date: June 2013


(Document is not valid after this date)
Review date: March 2012

Lead Executive/Director: Head of Communications and


Community Engagement
Name of originator/author: Sandra Fessey, Corporate
Services Manager
Target audience: WPCT employees
Version History

Version Date issued Issued To Brief Summary of Owners name


Change
V1.0 23.11.07 Dave Kendall, Trudi Addition of archiving Sandra Fessey
Wylde, Jayne procedures for FHS
Merriman, Tina and Childrens
Evans, Michael services
Whitefoot
V1.1 09.01.08 Information Sandra Fessey
Governance Group
V1.2 17.01.08 Information Page 6 - Additional Sandra Fessey
Governance Group clarification of
Associate Directors guidelines for use by
of Provider childrens services.
Services/Jane Pugh Changes to Policy list.
Changes to Appendix
V in respect of lifting
of boxes
V2 26 June 2008 Quality and Safety Formatted to fit with Sandra Fessey
Committee corporate
requirements.
Monitoring tool to be
added. Impact
assessment to be
added.
V2.1 23 March Jayne Merriman, Processes updated Sandra Fessey
2010 Judy Irving, Jannet following completion
Allen, Sandra of procurement
Fessey process.
V2.2 14 April 2010 Records P6 clarification of Sandra Fessey
Management Group diaries
V2.3 25 May 2010 Information P4 and 7 insertion Sandra Fessey
Governance Group of IG Policies in policy
lists
V2.4 02 June 2010 Judy Irving Addition of Business Sandra Fessey
Unit Administrators
V2.5 04 Jan. 11 Sandra Fessey Amendment of Jannet Allen
contact details

Worcestershire Primary Care Trust


Wildwood
Wildwood Drive
Worcester WR5 2LG
Date of Issue 27/7/2010
Location of document Corporate Services Administrator, Trust
Headquarters

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CONTENTS

SECTION PAGES

1. Background 4

2. Purpose and Scope 4

3. Roles and Responsibilities 4

4. Implementation 4

5. Archiving Offsite 5

6. Process for Archiving Records Offsite 5

7. Retrieval of records from Offsite Storage Facility 7

8. Implementation of the Policy 8

9. Review/Development of the Policy 8

10. Other Relevant Policies and Guidelines 8

11. Glossary of Terms 8

12. Reference List 9

Appendix A: Archiving Flow Chart 10


Appendix B: Retrieval Flow Chart 11
Appendix C: Archived Record Sheet 12
Appendix D: How to Fill a Box 13
Appendix E: Contact Sheet 14
Appendix F: Equality Impact Assessment 15

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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.

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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.

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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/records-
managementarchiving.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.

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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@whitefoot-


forward.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.

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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.

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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

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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.

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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.

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APPENDIX C
ARCHIVED RECORD SHEET

Please complete one sheet per box.

Barcode Number
Date patient
last
Patient seen/date of Directorate
NHS Patient date of death/type of Department/ Department/Service Storage Retention Disposal Lead (Job
Number Surname birth record Service Location Location Period Date Title)
Who is the
Where lead member
This is the the box Refer to Refer to of staff for
date of the Where you are will be DOH the DOH your
actual record Your dept based stored guidelines Guidelines department

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APPENDIX D

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APPENDIX E

AUTHORISED CONTACT SHEET

RECORD RECORD CONTACT CONTACT DETAILS


LOCATION TYPE PERSON
Trust Corporate/ Corporate Tel: 01905 760016, ext: 37202, Email:
Headquarters Commissioner Services Jannet.Allen@worcestershire.nhs.uk,
(Wildwood), records Administrator
Isaac Maddox
House,
Crossgate
House
Adult Patient health Business Unit Tel: 01905 733677 ext 31337
Therapies records Administrator Email: Naomi.seers@worcspct.nhs.uk

Community Patient health Business Unit Tel: 01905 733706


Hospitals records Administrator Email: Sue.ratheram@worcspct.nhs.uk
Adult Nursing
Childrens Childrens Business Unit Tel: 01905 733677 ext 31337
Services health records Administrator Email: Naomi.seers@worcspct.nhs.uk

Business Tel: 01905 681597


Support Email: Trudi.wylde@worcspct.nhs.uk
Manager
Family Health FHS records/ FHS Manager Tel: 01905 760149
Services Deceased Email: jayne.merriman@worcspct.nhs.uk
patient GP
records
Prison Prison health Administrators, Tel: 01527 785037
Services records HMP Hewell Email: Gail.healing@worcspct.nhs.uk /
ghealing@nhs.net or
Sharon.Prescott1@HMPS.gsi.gov.uk
Evesham Patient health Medical Tel: 01386 502431
Community records Records Email: Julie.Meadows@worcspct.nhs.uk
Hospital Manager
Tenbury Patient health Office Tel: 01584 810643,
Community records Manager Email:
Hospital Jenny.Biddlecombe@worcspct.nhs.uk

Princess of Patient health Administration Tel: 01527 488332


Wales records Manager/Site Email: Jeanette.Mann@worcspct.nhs.uk,
Community Manager
Hospital
(POWCH)

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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 Assessment of Impact


Race Low
Gender Low
Disability Low
Age Low
Sexual Orientation Low
Religion or Belief Low

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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 Corporate Development


Directorate Information Governance
Director Richard Stringfellow
Report produced by and Sandra Fessey, Corporate Services Manager
job title
Date report produced 17 June 2010
Date report published 7 July 2010

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