1.1 Scope of the Guidance
The guidance in this document has been extracted and abbreviated from the NHS Records Management Code of Practice, which states that:
All organisations and managers need to enable staff to conform to the standards in this Code. This includes identifying organisational changes or other requirements needed to meet the standards, for example, the people, money and correct tools required. Guidance, such as the Data Security and Protection Toolkit, and your own organisational management arrangements will help you identify any necessary changes to your current records management practices.
Those who have responsibilities for monitoring overall performance, like NHS England and the Care Quality Commission (CQC), help ensure effective management systems are in place.
It is relevant to organisations working within, or under contract to, the NHS in England. The Code also applies to adult social care commissioned or delivered by local authorities.
The Code provides a framework for consistent and effective records management based on established standards. It includes guidelines on topics such as legal, professional, organisational and individual responsibilities when managing records. It also advises on how to design and implement a records management system including advice on organising, storing, retaining and deleting records. It applies to all records regardless of the media they are held on. Wherever possible organisations should be moving away from paper towards digital records.
1.2 What is a record?
There is a definition of a record, which is useful to highlight. The ISO standard ISO 15489-1:2016 defines a record as:
“Information created, received, and maintained as evidence and as an asset by an organisation or person, in pursuance of legal obligations or in the transaction of business.”
1.3 Scope of records covered
The guidelines in this abbreviated Code apply to adult social care records. This includes:
- care records of adults who receive social care support
- jointly held records
- records held as part of a Shared Care Records programme
- staff records
- complaints records
- corporate records – administrative records relating to all functions of the organisation
1.4 The type of records covered
The guidelines apply regardless of the media on which the records are held. Usually, these records will be on paper or digital. Examples of records that should be managed using these guidelines include:
- care records
- administrative records, for example, personnel, estates, financial and accounting records, notes associated with complaint-handling
Examples of record formats that should be managed using the guidelines from this code:
- digital or computerised records
- paper
- photographs, slides, and other images
- audio and video tapes, cassettes, CD-ROM etc
- e-mails
- scanned records
- text messages (SMS) and social media (both outgoing and incoming responses from the patient or service user) such as x (formerly Twitter) and Zoom.
