health records management foundation l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Health Records Management Foundation PowerPoint Presentation
Download Presentation
Health Records Management Foundation

Loading in 2 Seconds...

play fullscreen
1 / 9

Health Records Management Foundation - PowerPoint PPT Presentation


  • 81 Views
  • Uploaded on

Health Records Management Foundation. Information Governance (IG) Policy Team NHS Connecting for Health. Key Learning Points. What is a health record Characteristics of full & accurate health records Why do we keep health records Performance measure for health records

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Health Records Management Foundation' - pascha


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
health records management foundation

Health Records Management Foundation

Information Governance (IG) Policy Team

NHS Connecting for Health

key learning points
Key Learning Points
  • What is a health record
  • Characteristics of full & accurate health records
  • Why do we keep health records
  • Performance measure for health records
  • Responsibilities for health records
  • Record Lifecycle Management
what is a health record
What is a health record?
  • A health record includes any information created by, or on behalf of, a health professional in connection with the care of a patient
what format can a health record take
What format can a health record take?
  • A health record can cover a wide range of material:
    • Handwritten medical notes
    • Computerised records
    • Correspondence between health professionals
    • Laboratory reports
    • X-ray films and other imaging records
    • Photographs
    • Videos and other recordings
    • Audio recordings
    • Printouts from monitoring equipment
characteristics of full accurate health records
Characteristics of full & accurate health records
  • Authentic
  • Reliable
  • Complete & unaltered
  • Processes & systems have integrity
  • Useable
  • Transferable
  • Structured
why do we keep health records
Why do we keep health records?
  • Communication between healthcare professionals
  • Continuity & evaluation of patient care
  • Defence of claims & investigation of complaints
  • GMC Requirement (“Good Medical Practice”)
  • Risk management
  • Clinical Governance
  • Resource utilisation
  • Research and education
  • Historical purposes
the health record should be
The health record should be…
  • Available in the right place at the right time to support effective patient/doctor contact and to provide continuity of care
  • Availability of the complete record when needed is a key determinant of the performance of Health Record Services
responsibilities for records
Responsibilities 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
record lifecycle management
Record Lifecycle Management

Create

Use

Retention

Appraisal

Disposal

Close Record

Be aware

Monitor

Control