Records Management PDF

RECORDS MANAGEMENT Records management (RM) is the supervision and administration of digital or paper records, regardless of format. It is a systematic and effective control of records (both paper and electronic). It aims to ensure that records are accurate and reliable, can be retrieved...

RECORDS MANAGEMENT Records management (RM) is the supervision and administration of digital or paper records, regardless of format. It is a systematic and effective control of records (both paper and electronic). It aims to ensure that records are accurate and reliable, can be retrieved speedily and efficiently, and efficiently, and are kept for no longer than necessary. It is crucial to all organizations. Unless records are managed efficiently it is possible to conduct business, to account for what happened in the past, or to make decisions are kept for no longer than necessary.  Records management activities include: creation Receipt Maintenance use and disposal of records Documentation may exist in: Contracts Memos paper files electronic files Reports Emails Videos instant message logs or database records. What is the concept? Information is “data, ideas, thoughts, or memories irrespective of medium.” Documents are any “recorded information or objects that can be treated as individual units Records are “information created, received, and maintained as evidence and information by an organization or person, in pursuance of legal obligations or in the transaction of business.” Archives are those records that have been selected for permanent preservation because of their administrative, informational, legal and historical value as evidence of official business IMPORTANCE OF RECORD MANAGEMENT To provide evidence of actions and decisions To support accountability and transparency To comply with legal and regulatory obligations, including employment, contract and financial law as well as the data protection act and freedom of information act To protect the interests of staff, students and other stakeholders Help to address complaints or legal processes. To support patient choice and control over treatment and services To support day to day business of the health care delivery To support evidenced based practice To assist clinical and other types of audits To support sound administrative and managerial decision making. To support improvement in clinical effectiveness through research BENEFITS OF RECORD MANAGEMENT  Saves time by ensuring that records can be found easily and quickly  Save space by preventing records from being kept longer than Necessary  Saves money by reducing storage costs and maintenance costs  Improves efficiently by ensuring records are readily accessible legally  Improves compliance by keeping records in line with legal and regularly requirements  Keeps records under control by preserving data and preventing accumulation control of referral material  Improves the quality of information, providing staff with access to accurate and reliable quality records security  Increases the security of confidential records continuity  Support business continuity and risk management  Records are managed efficiently and can be easily assessed and used  Records are stored as cost effectively as possible and when no longer required they are disposed of in a timely and efficient manner.  Complies with requirements concerning records and records management practices to ensure compliance with institution  Records of longer term value are identified and protected for historical and other research  It is a permanent written communication Record that documents information relevant to a client’s health care management. A record is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family and community.  Sample of records  Administrative records of Grants/Contracts  Bid documents  Blueprint of facilities  Consent forms-adult-minor  Endowment Fund Records  Equipment inventory reports  General ledgers  Meeting minutes  Payroll folders  Contracts-purchase lease rental, and etc. Records in the Nursing Office and Unit Administrative records: organogram, job description, procedure manual Personnel records: personal files, records Patient records send to medical center chief/medical director Leave record, duty roster, minutes of the meeting, budget etc. Miscellaneous: circular log book, formats, etc.  Principles of Record Writing  Nurses should develop their own method of expression and form in record writing  Records should be written with clearly and appropriately  Records should contain facts based on observation conversation and action  Select relevant facts and the recording should be neat, complete and uniform  Records should be written immediately after an interview  Records are confidential documents. SAFEKEEPING AND RELEASE OF RECORDS 1. Sentinel events 2. Anecdotal 3. Incident report 4. Kardex 5. Patients chart/records 6. 201 file  Nurses’ responsibility for record keeping and recording  Keep under safe custody of nurse  No individual sheet should be separated  Not accessible to patient and visitors  Strangers is not permitted to read records  Records are not handed over to the legal advisors without written permission of the administration  Handed carefully, not destroyed  Identified with bio-data of the patients such as name, age, admission number, diagnosis, etc.  Never sent outside the hospital without the written administrative permission Nursing Administrator’s Responsibility  Protection from loss  Safeguarding its concerns  Completeness  Responsibility for nurse notes  Admission record  Scientific value of the nurse notes  Record of order carried out Individual Staff Record A separate set of record is needed for staff, giving details of their sickness and absences. Ward Records Deducting or increase in beds Change in medical staff and non-nursing personnel for the ward The introduction and patient of support Characteristic of a Good Record and Reporting Accuracy Consciousness Thoroughness Up to date Organization Confidentiality Objectivity  Purposes of Record  Supply data that are essential for programmed planning and evaluation  Provide the practitioner with data required for the application of professional services for the improvement of family health  Used as tools of communication between health workers the family and other development personnel  Shows the health problem in the family and other factors that affect health  Indicates plan for future  Provides baseline data to estimate the long term changes related to services  Administrative Purpose of clinical records  Legal documents  Research or statistics rates  Audit and nursing audit  Quality of care  Continuity of care  Informative purposes  Teaching purposes of students  Diagnostic purposes Importance of Records in Hospital (For individual and family)  Serve the history of the client  Assist in the continuity of cares  Evidence to support if legal issues arise  Assess health needs: research and teaching For the Doctor Serve the guide for diagnosis, treatment, follow up and evaluation Indicate progress and continuity of care Self-evaluation of medical practice Protect doctor in legal issues Used for teaching and research For the Nurses Document nursing service rendered Planning and evaluation of service for future improvement Guide for professional growth Communication tool between nurse and other staff involved in the care Indicate plan for future For Authorities  Statistical Information  Administrative control  Future reference  Evaluation of care in terms of quality, quantity and adequacy  Help supervisor to evaluate service  Guide staff and students  Legal evidence of service rendered by each employee  Provide justification of expenditure of funds  What is the records lifecycle? Create/receive - starts when records are either received from an external source or created internally. The objectives of this initial stage are:  Create complete and accurate records that provide evidence of the organization’s functions, activities, decisions, transactions, procedures, etc.  Identify and apply an appropriate security classification  Distinguish between records and non-record copies or working documents, to be able to appropriately segregate them in the filing system  Place the record in an organizational classification scheme (or file plan) either in paper (e.g. in a filing cabinet or a binder) or in electronic version (e.g. on a shared drive or in a system) to ensure that it’s preserved within its context  Active phase It means that they are often used, shared between colleagues, retrieved to support day-to-day business and referred to.  Identify and apply an appropriate security classification  Distinguish between records and non-record copies or working documents, to be able to appropriately segregate them in the filing system  Place the record in an organizational classification scheme (or file plan) either in paper (e.g. in a filing cabinet or in a binder) or in electronic version (e.g. on a shared drive or in a system) to ensure that it's preserved within its context Preserve the integrity of the record, which means ensuring that it has not been altered after completion Maintain its usability which means making it available for all colleagues who need an access to the record to do their job Facilitate identification and preservation of records with permanent retention  Inactive phase. During this stage, we should free up space in our offices to new records, but we need to ensure keeping inactive records handy. The objectives of this stage are:  Identify the records that are not required to be stored in the primary office space (paper) or systems/shared drives (electronic)  Organize and list them  Transfer them to the local Records Center (for field missions the local Records Center within mission area; for HQ offices the ARMS Records Center)  Retrieve only those records that are needed from time to time  Disposition phase The objectives of this stage are: Identify records with archival value (permanent retention), list them, organize them Identify records due for disposal/destruction, list them, gather necessary approvals for the destruction and proceed with an environmentally friendly destruction process