Records management is the supervision and administration of digital or paper records, regardless of format. It is a systematic and effective control of records that aims to ensure that records are accurate and reliable, retrievable, and efficient in storage and format. This involves creation, storage, use, maintenance, and eventual disposal of records deemed no longer necessary. Its principal goal is to keep the necessary documentation accessible for both business operations and compliance audits.
Importance and Benefits of Record Management
- To provide evidence of actions and decisions, which supports accountability and transparency. This can aid in protecting the interests of staff, students, clients, and other stakeholders and helps to address complaints or legal processes.
- To comply with legal and regulatory obligations, including employment, contract and financial law as well as the data protection act and freedom on information act.
- To support patient choice and control over treatment and services (consent, waivers).
- To support day-to-day business of healthcare delivery.
- To support evidence-based practice (EBP) and to support improvement in clinical effectiveness through research.
- To assist in clinical (and other forms of) audits, and to support sound administrative and managerial decision making.
- Saves time by ensuring that records can be found easily and quickly, improving efficiency.
- Saves space by preventing records from being kept longer than necessary.
- Saves money by reducing storage costs and maintenance costs.
- Improves compliance by keeping records in line with legal requirements for storage and requisition.
- Keeps records under control by preserving data and preventing accumulation of ephemeral material.
- Improves the quality of information, providing staff with access to accurate and reliable quality records security.
- Increases the security and continuity of confidential records.
- 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
Records
Records are permanent written communication that documents information relevant to a client’s health care management. For example, a patient chart is a continuing account of client health care status and needs. It is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family and community. They serve to manage and conduct business efficiently, available for use to account for record-keeping (historical info) and for decision-making. Physical storage on-site or at a storage facility, and digital storage on storage media in-house or on the cloud are all options for storage of their appropriate record formats.
Purposes of Records
- Supplying data that are essential for program planning and evaluation
- Providing 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.
Purposes for Administrators
- Legal documents: poisoning, assault, rape, leaving against medical advice (LAMA/HAMA/DAMA)
- Research or statistics rates
- Audit and nursing audit
- Quality of care
- Continuity of care
- Informative purposes: MEN census
- Teaching purposes for students
- Diagnostic purposes: test reports
Purposes for the Hospital, Individual, and Family
- Serve the history of the client
- Assist in the continuity of caring
- Evidence for legal issues
- Assessing health needs for research and teaching
Purposes for Nurses
- Document nursing service rendered
- Planning and evaluation of service for future improvement
- Guide for professional growth
- Communication tool between nurses and other staff involved in the care of a patient
- Indicate future plans
Purposes for Physicians
- Serve the guide for diagnosis, treatment, follow-up, and evaluation
- Indicate progress and continuity of care
- Self-evaluation of medical practice
- Protect the doctor in legal issues
- For teaching and research
Purposes for Authorities
- As a basis for 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
Types of Records
These may exist in the form of contracts, memos, paper files, electronic files, reports, emails, videos, instant message logs, or database records. Some examples include:
- Administrative records of grants or contracts
- Bid documents
- Blueprints of the facility
- Consent forms for adults and minors
- Endowment fund records
- Equipment inventory reports
- General ledgers
- Meeting minutes
- Payroll folders
- Contracts such as purchases, leases, rentals, etc.
Within the Nursing Office and Unit,
- Administrative records (organograms, job descriptions, procedure manuals, leave records, duty rosters, minutes of the meeting, budget, etc.),
- Personnel records (personal files, records), and
- Patient records are kept.
Record Writing
Nurses should develop their own method of expression and form in record writing. They must be CLEAR:
- Confidential: limited to only those who are authorized
- Legible: understandable in content, language (recognized abbreviations, terminology), and writing
- Empirical: based on facts and observations
- Appropriate: only pertinent information is kept
- Relevant: important and timely (written immediately)
Characteristics of Good Recordkeeping
- Up-to-date
- Accurate
- Thorough
- Organized
- Confidential
- Objective
Safekeeping
Records may require safekeeping in order to maintain confidentiality, privacy, and dignity, and for legal reasons. Examples of these records include:
- Sentinel Events
- Anecdotal Records
- Incident Reports
- Kardex
- Patient Charts/Records
- 201 File: employee files containing personal, financial, and employment information; an employee profile.
Individual Staff Record
Records exist for the employment status and information of all personnel on the ward. This includes information about absences, leaves, etc.
To this end, the nurse must keep these records under their safe custody, ensuring that no individual sheet is separated, no record is openly accessible to patients and visitors, records are not handed to legal advisors or sent outside without written permission from administration, and specific to each patient with name, age, and admission number.
Additionally, the nursing administration ensures completeness and protection from loss, safeguarding content, responsibility for nurse’s notes, admission records. The ward records, including changes in bed space, changes in personnel and staff
Phases of Records Management
flowchart LR
1(Creation/Reception)
2("Active Phase (On-site)")
3("Inactive Phase (Storage Facility)")
4(Disposition)
1-->2-->3-->4
- Creation/Reception: the records are either received from an external source or created internally. This aims to:
- 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 for maintaining proper accessibility.
- Distinguish between records and non-record copies for appropriate segregation in the filing system.
- Place the record in an organizational classification scheme (file plan) either in paper or in electronic version to ensure that it’s preserved within context.
- Active Phase: especially for records that are often used, shared, referenced, or retrieved to support day-to-day business.
- Identify and apply an appropriate security classification.
- Distinguish between records and non-record copies for appropriate segregation in the filing system
- Place the record in an organizational classification scheme (file plan) either in paper or in electronic version to ensure that it’s preserved within context.
- Ensure the integrity of the record, with its content not being altered or damaged during use. The usability of the record must be maintained available to all who need access to the record.
- Facilitate identification and preservation of records with permanent retention (inactive phase).
- Inactive Phase: offices are cleared for new records, while keeping inactive records available for retrieval. This stage:
- Differentiate, organize, and list records for keeping and for storage, and transfer “inactive records” to the local records center, headquarters, or whichever primary storage facility is being used.
- Retrieval of records occasionally required.
- Disposition: storage facilities are cleared for more storage, while keeping records with archival value for permanent retention.
- Differentiate, organize, and list records for keeping and for disposal, and gather the necessary approvals for destruction and proceed with an environmentally-friendly destruction process.