SH IG 16

Archiving Guidelines and Procedure

Information Lifecycle Policy
(Records Management)

Version 2

Summary: These guidelines provide practical archiving guidance in

relation to Southern Health NHS Foundation Trust
(SHFT) requirements within the Information Lifecycle
Policy.

Keywords (minimum of 5): Records, files, folders, versions, archiving

(To assist policy search engine)

Target Audience: Southern Health NHS Foundation Trust employees,

Non-Executive Directors and Contractors.

Next Review Date: August 2018

Approved & Ratified by: Information Governance Date of meeting:

Group 13/07/2015

Date issued: July 2015

Author: Rachel Lloyd

Records Manager

Sponsor: Helen Reading, Associate Director of Technology

Archiving Guidelines and Procedure

Records Manager 1
Version 2
July 2015
Version Control
Change Record

Date Author Versio Page Reason for Change

n
09/08/2011 L Barrington V1 All Review and combination of previously HPFT
& HCHC policies and procedures
09/07/2012 R Gray V2 Remove appendices
26/06/2015 R Lloyd V2 All Update and review
Update re. National Archives 20 year rule for
retention

Reviewers/contributors

Name Position Version Reviewed

& Date
CIASG 01/08/2012
IGG IG Leads and Members V2 13/07/2015

Archiving Guidelines and Procedure

Records Manager 2
Version 2
July 2015
 Contents

Page

1. Introduction 4
2. Rationale 4
3. Aims 4
4. Scope 4
5. Storage of records on Trust-owned premises 5
6. Procedure for archiving paper records 6
7. Procedure for retrieval of archived records 9
8. Procedure for review and destruction of records 10
9. References and sources of Information 11

Archiving Guidelines and Procedure

Records Manager 3
Version 2
July 2015
 Archiving Guidelines and Procedure

These Guidelines and Procedure form part of and should be read in conjunction with the
Information Lifecycle (Records Management) Policy

1. Introduction

1.1 These guidelines provide practical archiving guidance in relation to Southern Health NHS
Foundation Trust (SHFT) requirements within the Information Lifecycle Policy. They adopt
the NHS Records Management: NHS Code of Practice which provides specific retention
guidelines for many different categories of records and must be read alongside these
guidelines. They can be found at http://www.southernhealth.nhs.uk

2 Rationale

2.1 Compliance with the Freedom of Information Act 2000 and the Data Protection Act 1998
require robust records management.

2.2 This guidance supports compliance with CQC, NHS Litigation Authority and Information
Governance standards for the maintenance and storage of records.

3 Aims

3.1 The aim of these guidelines is to disseminate good practice, create uniformity across the
Trust, and to raise awareness and achieve compliance with the aforementioned standards.

4 Scope

4.1 These guidelines cover all records/information in all media types, with the exceptions listed
below.

4.2 These guidelines refer to archiving both on site and at the external facilities procured by the
Trust.

4.3 These guidelines do not apply to:

General Practice
Dental Practitioners
Other independent practitioner records or x-ray films
Records that are used by Community Hospitals that are part of the associated
acute care Trust

Hospital case-notes are shared between Southern Health Community Hospitals and acute
NHS Trusts1. Retention, archiving and destruction of these records are managed by these
Trusts under Service Level Agreements and are subject to joint agreements with them.

1
UHSFT, BNHFHT, WEHCT, PHT, SHCT
Archiving Guidelines and Procedure
Records Manager 4
Version 2
July 2015
4.4 Records or parts of records which are subject to any known litigation; Child Protection
proceedings or Freedom of Information requests or appeals must be retained until no
longer required for these purposes (litigation dossiers 10 years).

4.5 If any record is retained beyond the minimum retention period designated in the Retention
Schedule the reason for retention must be documented, including a date for review of this
decision. On review the retention decision must either be re-applied with a further review
date set or the record destroyed as appropriate.

4.6 Any record deemed by the appropriate senior healthcare professional or manager to be of
key significance for teaching, research purposes or of historic interest should be retained
locally for permanent archiving or deposited with National Archives. Such records must be
clearly marked For permanent retention. (Any record kept more than 20 years after the
last entry requires the approval of the Keeper of Public Records (Public Records Acts 1958
and 1967).

5. Storage of records on Trust-owned premises

5.1 General principles

All records whether electronic/paper/ confidential or open to access must be stored in an
easily accessible filing system, in a format appropriate to the record and with its own
storage solution.

5.1.1 Conditions should be appropriate for the storage of records i.e. protected against fire, flood
and theft, with filing and lighting systems compliant with health and safety requirements,
and kept in a clean and tidy condition.

5.1.2 Movement of paper records into and out of formal filing storage must be tracked. This
should include the access and return dates, takers name, contact details, signature, and
reason.

5.1.3 Two years of inactive paper records should be kept at service/departmental bases. Older
records should be sent for external archiving according to the arrangements agreed for the
service/department and the guidance provided in this procedure.

5.2 Confidential or Personally Identifiable Records

5.2.1 All records containing personal identifiable information (PID) and other confidential paper
records must be stored in a safe and secure location, in a locked cupboard or filing cabinet
in a room which is kept locked at all times when not in use.

5.2.2 Access to these records must be controlled and restricted to designated staff to maintain
security of information.

5.2.3 All access to paper records of this type must be recorded for audit purposes. A tracker
sheet is a simple way of achieving this. Please refer to Archive Toolkit for examples.

Archiving Guidelines and Procedure

Records Manager 5
Version 2
July 2015
6 Procedure for archiving paper records

6.1 Preparation of records for archiving

6.1.1 Departments should refer to the appropriate retention schedule for their records.2

6.1.2 Only records with the same review date should be stored in the same box. This is to
simplify review and facilitate easy destruction. The review date is calculated from the date
of the last entry in the record. Administrative records from different years but with the
same review date may therefore be stored together.

6.1.3 Healthcare records should only be stored by archive year (see 6.2 below).

6.1.4 If documents are misfiled this may make retrieval impossible and result in the wrong
records being destroyed or preserved for longer that the retention schedule
recommends.

6.1.5 Files should be weeded or culled before archiving. This means removing documents
which have no archival value (eg contacts lists, room-booking details in meeting papers,
duplicates). Papers should be removed from lever arch files, box-files, binders; spring clips
etc and placed in plain or archive envelopes, clearly marked with the contents. Where
practicable, plastic pockets should also be removed and papers stapled together.

6.1.6 Copies of records already held elsewhere (e.g. invoices held on the SBS system) should
not be archived.

6.1.7 Signed and/or master copies of meeting records should be archived by the person
responsible for managing those meetings. All other copies should be shredded.

6.1.8 Copies of information already in the public domain e.g. internet downloads and printed
published documents must not be archived and should be destroyed.

6.1.9 Healthcare records for an individual patient should be fastened together as a single record
for that service/department. The patients NHS number must be included to enable cross-
referencing to their electronic record and other paper records.

6.1.10 Patient-held records will be retrieved for archiving on conclusion of treatment and archived
by year of last entry. When records are sent to external archive storage no records should
be retained on-site.

6.1.11 A detailed listing is required of the contents of each box, one copy in the box, a second
(preferably electronic version) kept by the department/service administrator/ manager, and
a third sent to the Records Manager to keep alongside the corporate list.
6.1.12 If an amendment is required to a box that has already been indexed, all copies of the
contents list must be updated. This will facilitate the retrieval of records when they are
required.
6.1.13 A detailed spreadsheet must be completed for all records stored with an external archive
company please refer to Toolkit for more information. This has to be completed and
checked before box reference numbers can be issued.

2
Records Management NHS Code of Practice Section 2
Archiving Guidelines and Procedure
Records Manager 6
Version 2
July 2015
6.2 Archive Year

6.2.1 Records should be archived throughout the year as they become inactive; and reviewed on
an annual basis.

6.2.2 For all health records except those relating to children; the archive year is the calendar year
in which the last entry was made. The review date is the January in the appropriate
number of years later. For example a record with the last entry during April 2009 and an 8
year retention period will be due for review in January 2017. Please refer to the Archive
Toolkit for further information.

6.2.3 The retention period for childrens records is calculated from the birth date of the child, and
so should be archived by that year.

6.2.4 School Nursing and CAMHS records should be archived when the child leaves the
area/service. It is appropriate to archive School Nursing records at the end of the school
year, giving a 1st September review date.

6.2.4 For financial and some administrative records it is more appropriate to archive by financial
year (FY) ie 1st April to 31st March. Boxes of such records should be marked with financial
year (eg FY 2006-7). The review date will be 1st April of the year appropriate to the type of
record. Please refer to Archive Toolkit for further information.

6.3 Archive Boxes

6.3.1 All records destined for commercial storage should be stored in standard archive boxes.
These are obtainable from your stationery supplier. On no account should transfer
cases be sent for commercial storage due to the greatly increased costs involved.

6.3.2 For health and safety reasons no box should weigh more than 16KG. Boxes exceeding this
weight will be returned.

6.3.3 Box level indexing must not enable the identification of individuals. If a new box is
necessary in the middle of a letter series the index must be recorded for example as A
Cla, Cle end F. A Clark, and Clerk to Fox is not acceptable.

6.4 How and when to archive

The guidance below paraphrases the NHS Records Management Code of Practice the
full document should be referred to.

6.4.1 Administrative records As retention periods for these records are relatively short, it may
be most appropriate to archive these on site. Service/departmental Managers are
responsible for ensuring that records are destroyed promptly and securely upon expiry of
retention periods and the secure destruction of paper copies of records held elsewhere or
in electronic format.

6.4.2 Corporate records Master copies of Trust Board and associated committee papers
should be retained indefinitely. After one year has passed the records should be indexed
and stored with an external archive company. After 20 years they should be transferred to
the National Archives.

Records of minor meetings must be weeded, archived, reviewed and authorised for
destruction by the member of staff responsible for the meeting, taking into account retention

Archiving Guidelines and Procedure

Records Manager 7
Version 2
July 2015
 guidelines. Other staff must not retain copies of the meetings they attend for longer than
required for immediate business purposes.

6.4.3 Litigation and complaints records These must be kept for a minimum 10 years. They
should be archived annually by reference number and locality.

6.4.4. Serious Incident records e.g. suicide/homicide investigations and reports These
must be kept for a minimum of 30 years. The Central Governance Team is responsible for
keeping an electronic version of the Root Cause Analysis Report and supporting
documentation. Local teams are responsible for keeping copies of statements and
supporting evidence, which must be kept on a local catalogue if stored off site.

6.4.4 Finance records Finance records will be held by NHS Shared Business Services /
Xansa (SBS) and within the archive stores at the Finance Department. Finance Managers
are responsible for ensuring that records are maintained and destroyed as per Trust Policy,
legislative requirements and the retention schedule.

6.4.5 Staff records Departmental/service-managers are responsible for the safe-keeping of the
personnel files of all their current staff. Leavers files are to be collated centrally, stored and
indexed alphabetically by surname and year of leaving the organisation. The index must be
maintained and include tracking information (eg transfers of files to other
departments/services) and leaving/retirement dates (to enable review/destruction).
Records of current training will be kept electronically. Older training records which need to
be retained will be kept with personnel files. Files may be weeded when they become
inactive but in general must be retained for 6 years after the individual leaves the Trust.

6.4.6 Registration Authority (RA) records These records are the responsibility of the
Registration Authority Manager who will follow national and Trust Registration Authority
Policies.

6.4.7 Occupational Health records Inactive records (i.e. of staff who have left the
organisation) should be indexed by name, archived alphabetically by leaving year and kept
for 6 years after the individual leaves the organisation. Records of personnel who have or
may have been exposed to hazardous substances (e.g. asbestos) or x-ray radiation must
be extracted for longer retention when records are archived. They should be indexed and
stored alphabetically by review year.

6.4.8 Health Visiting Health Visiting records should be transferred to the appropriate Health
Visiting or School Nursing service as the child moves on. Any records which cannot be
transferred should be archived throughout the year as they become inactive by year of
birth. Boxes should be marked with the calendar year of birth with a 1st January review
date 26 years after the latest birth date. Family records should be archived with the records
of the youngest child.

6.4.9 School Nursing - Following a move or transfer to a school outside the Trust area, or
transfer to private school, paper records should be placed in alphabetical order in boxes by
year of birth. Following the death of a child, paper records should be placed in alphabetical
order by year of death. To determine the date of review use the retention guidelines and
refer to the NHS retention schedules.

6.4.10 Looked after and adopted children These records must be archived separately
because they have a 75 year retention. When they become inactive School Nursing and
Health Visiting records must be amalgamated with Looked after Childrens records so that
they can be archived together.

Archiving Guidelines and Procedure

Records Manager 8
Version 2
July 2015
6.4.11 Community Nursing, Community Rehabilitation and Rapid Response Records
should be stored in alphabetical order by calendar year of discharge, death or last
treatment. There is no requirement to separate discharges from deceased patients (RIP),
however, if they have been separated this should be indicated on the box label/index.
Records should be sent to locality administrative bases for preparation and collation for
storage.

6.4.12 Out-patient therapy services, Orthopaedic Choice and Podiatry The initial procedure
is the same as for Community Nursing. Transfer cases may be used for on-site storage (for
Health & Safety reasons when records are frequently retrieved) but must be stored
securely. See 6.1.10 for Child Therapies. Many of these records are stored commercially.

6.4.13 Minor Injuries (MIU) - Records should be stored in alphabetical order (at Lymington
Hospital in six-month periods ie January to June and July to December). Adult and child
records must always be stored separately. Boxes must be identified clearly as adult or
child attendances and marked with the half year. The destruction date is calculated from
the date of the last record (eg January June 2007. Review 1st July 2017). Lymington
MIU records are currently stored and managed by Filestore. Please refer to Archive Toolkit
for further information.

6.4.14 Out of hours GP Service Child and adult records must be separated. Records should
be stored in treatment date order by month and year.

6.4.15 Dental Services Child and adult records must be separated. Records should be stored
A to Z by surname and then by treatment year.

6.4.16 Theatre and other registers Records should be retained on-site. Registers over 5 years
old should be appraised for permanent preservation and transferred to National Archives by
the Records Manager.

6.4.17 Imaging Records must be kept for 8 years. Some of these records are stored
commercially by Filestore. Records should be stored by patient number and treatment
year. Imaging is now largely electronic, but older x-films must be retained in appropriate
environmental conditions to preserve the records according to the retention period.

6.4.18 Diaries (clinical) - The owners name, service and base must be written clearly on the
diary. At the end of the year diaries should be collected and stored securely at the service
base. Diaries should be securely destroyed after 2 years. Diaries should not be used for
the recording of clinical information. However, if such information is in a diary it must be
copied into the patients health records (to enable the diary to be destroyed).

6.5 Missing Records Please refer to SH IG 03 Mislaid or Lost Clinical Records Procedure.

7 Procedure for retrieval of archived records

7.1 A tracer should be left in the box to show when a paper record is retrieved, giving the date
of retrieval and contact details, document title (and/or other relevant information to identify
the record which has been retrieved or and patients details (health records). The return
date should also be recorded.
7.2 Records in an external archive may be retrieved by contacting the relevant storage
company, who will require the signature of the authorised Service/Department Manager.
The individual file or box containing the record will be delivered to the site. If the record is

Archiving Guidelines and Procedure

Records Manager 9
Version 2
July 2015
 required for longer than one week and is to become active again an entry to reflect this
should be entered into the tracer and the box must be returned to the storage company.
Remember to update your local records inventory to reflect that the file has become active
again.

7.3 If any box is retrieved permanently from commercial storage the Service/Department
Manager must inform both the storage company and if applicable, the Records
Manager and the that the retrieval is permanent. Failure to do so will incur
unnecessary continued storage charges. (Permanent retrieval also incurs a retrieval
charge.)

In most circumstances records can be retrieved from commercial storage free of charge the
next working day (and in an emergency can be retrieved the same day, although this has
cost implications and should be avoided unless absolutely necessary).

8 Procedure for review and destruction of records

8.1 Records stored on Trust premises must be reviewed at least annually, usually in January or
April, to identify those records whose retention period has expired. Service/ Departmental
Managers should authorise disposal.
8.2 Records must either destroyed on site or arrangements made with a Trust approved
contractor to carry out this task. Please refer to the Archive Toolkit for further information.
An appropriately detailed certificate of destruction must be obtained and forwarded to the
Records Manager.
8.3 When records stored commercially become due for review the storage company will
contact the appropriate account holder for authorisation. Following authorisation the
storage company will securely destroy the records and issue a certificate of destruction.
This should be sent to the Records Manager.

8.4 If records are deemed likely to be of permanent value the Records Manager must be
consulted to appraise and arrange for transfer to National Archives if appropriate. Such
records will be any document dating from before 1948, registers, records of inspection by
Board of Hospital Managers, old photographs, and records series of particular interest and
major corporate documents of Southern Health NHS Foundation Trust and its predecessor
organisations. The Records Manager will maintain a list of the records of the Trust and
predecessor organisations held by National Archives.

8.5 Destruction of confidential records must be secure and complete. Records must therefore
be destroyed by shredding, combustion or pulping.

8.6 Destruction certificates should be retained to provide legal proof of destruction in case the
records are subsequently requested for disclosure, litigation purposes or under Freedom of
Information or Data Protection legislation. The following should be recorded: a list of the
records destroyed, when this took place, the name of the person who authorised
destruction, who carried out the process and the reason for destruction. (This should relate
to the Retention Schedule.)

8.7 If a record is inappropriately destroyed (eg a record which is subject to a request under the
Freedom of Information or Data Protection Acts) the appropriate Service or Department
Manager must record this as an incident on Safeguard and carry out an investigation.
Inappropriate destruction may lead to disciplinary action being taken.

Archiving Guidelines and Procedure

Records Manager 10
Version 2
July 2015
9 References and sources of Information

Care Quality Commission http://www.cqc.org.uk

Clinical Negligence Scheme for Trusts: Clinical Risk Management Standards for PCTs,
NHS Litigation Authority http://www.nhsla.com
National Archives (Public Records) www.nationalarchives.gov.uk
HSCIC Information Governance Toolkit - https://nww.igt.hscic.gov.uk/Home.aspx

Archiving Guidelines and Procedure

Records Manager 11
Version 2
July 2015