1. Policy overview
The reasons for the Policy:
The practice regards the confidentiality of patient and staff information as prime importance. As part of staff induction, all staff are trained to ensure that Patient information remains within the confines of the Practice premises. It is important that staff should sign a confidentiality undertaking to ensure the security of patient, practice and personnel information, verbal, written or electronic is protected.
2. Applicability
The policy applies to all employees and Partners, and also applies to other people who work at the Practice e.g. locum GP's, non-employed nursing staff, temporary staff and contractors.
The work of the practice includes access to personal, written and computerised patient information, and at all times this should be treated as confidential and protected from unauthorised disclosure. It is an express condition of employment that no employee may divulge to a person outside of the Practice such information or/and the outward transmission of any such information or data.
3. Procedure
The terms of the Policy:
Records Management
Records Management will be the responsibility of the Lead GP, delegated to the Practice Manager.Records containing personal or patient identifiable information will be managed in accordance with the principles of the Data Protection Act. The Practice has a file structure of filing both patient and non patient information. Paper patient records are filed alphabetically and stored in an appropriate way. Paper Non patient and business information is stored in either the Practice Manager’s office or in the Practice archive.
The documents held in the Practice Manager’s office are current documents needed regularly by the Practice Manager or reference information. The Practice Manager will keep an up to date contents list showing what is in the filing cabinets and where they are stored. All documents placed in the archive are no longer current, but need to be retained for a period of time. These documents must be placed in files, in clearly labelled boxes and with destruction dates written on the file and the box where appropriate. These dates will be in line with the Practice document retention schedule.
Patient electronic records are stored in the Practice clinical system and must be kept tidy. This involves effective read coding for ease of searching and ensuring that sections such as the problem lists are kept to a minimum. This is done by checking the list or consultation notes before entering a first instance of a problem.
Non patient electronic records are stored either on the Practice shared drive, or for sensitive business / personnel records on the hard drive of the Practice Managers computer. The latter is regularly backed up onto a flash drive.
Retention and Destruction of Records
The Practice has a document retention schedule that has been drawn up in line with current NHS Guidelines (Department of Health (Whitehall) guidance, WHC (2000) 71 and HSC/217 1999 and WHC (99) 7.
Both paper and electronic records should be regularly reviewed and obsolete or out of date records should be destroyed in a secure fashion (confidential shredding or permanent deletion from the computer files)
Outcome
Conclusion
Effective storage and management of paper and electronic records is important to ensure that information is easy to locate and access. Record location lists need to be kept up to date also. In addition to ensuring information is easily accessible, regular management of information stores helps to ensure they do not become cluttered with information that is no longer relevant.