Corporate Records Procedure

8/13/2019 Corporate Records Procedure

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Corporate Records Procedure

CATEGORY: ProceduresCLASSIFICATION: Governance

PURPOSE To support the RecordManagement and InformationLifecycle Policy

Controlled Document

Number:

469

Version Number: 1

Controlled DocumentSponsor:

Director of Corporate Affairs

Controlled DocumentLead:

Senior Manager Corporate Affairs

Approved By: Director of Corporate Affairs

On: April 2010

Review Date: March 2012

Distribution:

EssentialReading for:

Information for:

All staff who deal with CorporateRecords

All staff

ONTR

OLLED

DOCU

MENT


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Contents

Paragraph Page

1 Procedure Statement 3

2 Scope 3

3 Framework 3

4 Duties 8

5 Implementation and Monitoring 8

6 References 9

7 Associated Controlled Documents 9

Appendices

Appendix A Guideline Naming Convention 11

Appendix B Typical thought tree used during appraisal process 20

Appendix C Retention Schedule for Corporate Records 21


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1 Procedure Statement

1.1 This Procedure sets out the detailed steps to be taken when creating,naming, referencing, filing, storing, accessing, transferring, tracking,appraising, archiving and disposing of corporate records in accordancewith the and Record Management and Information Lifecycle Policy (thePolicy).

1.2 This procedure may be amended from time to time by authority of theDirector of Corporate Affairs, provided that such amendments arecompliant with the Policy.

2 Scope

2.1 This procedure covers all corporate records held by the Trust. A corporaterecord documents the effective management of the Trusts records toenhance the Trusts performance and includes, but is not limited topersonnel, estate, finances, and purchase and supplies records.

2.2 This procedure applies to all individuals employed by the Trust includingcontractors, volunteers, students, locum - agency staff and staff employedon honorary contracts who come into contact with corporate records.

2.2 The aim of this procedure is to:

Inform staff and management of the importance of recordsmanagement to the Trust, both strategically and operationally;

Describe in general terms responsibilities for corporate records andin particular refers to the role of the Records Manager;

Provides a basis for accountability by ensuring relevant, evidentialinformation and documentation is maintained in a retrievable form;

Ensure compliance with relevant legislation;

Meet the Trusts business need for authentic, reliable and usablecorporate records.

3 Framework

This section describes the broad framework for the creation, referencing,


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3.1.2 Electronic recordsare any records which are held electronically such asemails, attachments and web pages on the internet or intranet.

3.1.3 The term records life cycle describes the life of a record from itscreation/receipt through the period of its active use, inactive retention(such as closed files which may still be referred to occasionally) and finallyeither confidential disposal or archival preservation.

3.1.4 Operational Unitmeans a division or department within the Trust which

operates specific activities and fulfils a certain function as for exampleFinance, Estates, IM&T, Procurement, Corporate Governance,Communications or HR.

3.2 Creation

3.2.1. Records should be created when there is a need to remember the detailsof an event, decision or action such that anyone needing to recourse to the

facts can rely on and acknowledge that the representation is accurate. Inparticular, records should be created to:

Provide evidence of policy, decisions, actions or activities;

Provide compliance with rules, regulations and legislationappropriate to the organisational context;

Inform colleagues of what has been done or decided;

Act as a reminder of how something has been done;

Track progress of a project or process;

Facilitate an audit or examination of the Trust by anyoneauthorised;

Protect the legal and other rights of the Trust, its patients, staff andany other people affected by its actions.

3.2.2 It is not possible to prescribe exactly the content of all corporate recordregisters as this will depend on the nature of the business to bedocumented. However, as a general rule, the following constituents shouldalmost always be present in any record register:

The identity of person or equipment creating the record


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with the NHS Code of Practice 2006 and any other legislation in which theunit operates.

3.2.4 Each operational unit will further have in place means of locating thewhereabouts of all registered records and wherever practical andappropriate, this will be an electronic tracking system.

3.3 Referencing

3.3.1 Each operational unit should develop specific rules on referencing, titling,indexing and protective marking of those electronic records which it

typically holds in order to ensure that the information can be identified andretrieved when required and without delay.

3.3.2 The following are 5 general principles which should be followed by alloperational units irrespective of the nature of their business:

Each record must be given a unique name (preferably analphanumerical name).

The name should be meaningful and closely reflect the recordscontent.

Different elements of the name should be expressed in astructured and predictable order.

The most specific information should be located at the beginningof the name and the most general at the end.

Records which are linked should be given a similarly structuredand worded name.

Appendix A sets out 13 guidelines which aims to assist operational unitswith the drafting of their business specific naming convention.

3.4 Filing and Storage

3.4.1 Appropriate filing and storage of records is essential to ensure theirauthenticity and reliability and it enables the Trust to obtain the maximumbenefit from quick and easy retrieval of information.

3.4.2 Each operational unit will adopt a filing system which:

Provides a classification scheme to group or link related records;


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Documents the process and outcome of appraisals.

3.4.3 Each operational unit will choose suitable storage equipment for theirpaper records. The physical location of paper records will be based uponthe following criteria:

Context in which they were documented

Compliance with Health & Safety regulations

Security levels required

Risk assessment (in particular environmental conditions, flood andfire protection; system hacking, crashes, viruses and theft)

User needs

Record types

Size and quantity

Usage and frequency of retrieval

Ergonomics, suitability, space efficiency and price

Retention period

Legislation

3.4.4 In the context of electronic corporate records, it is important to rememberthe distinction between a record and a document. Not all documents

are records. A document becomes a record when it becomes part of theTrusts corporate information memory. Electronic records should solely bekept in the corporate system (e.g. the corporate network drive or a sharedfolder (e.g. I drive), whereas documents may be kept in a personal folderon the local PC drive (e.g. C drive) or a personal network drive (e.g. Hdrive). Where a dual system is maintained, electronic records shouldfurther be cross-referenced to their paper counterparts.

3.4.5 Electronic records are more susceptible to corruption than paper recordsand therefore encryption, password protection, automated access controland audit trails should be used where necessary. Electronic records mustbe subject to a back-up regime. The Trust has adopted an Emergency andDisaster Recovery Strategy which includes retrieving electronic records inthe event of a system failure.


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Effective finding aids to identify and locate the record

Authorisations for access or access restrictions details For highly sensitive information security clearance requirements

For paper records a log book to monitor where, when and by whoma record was retrieved and when the record is due for return.

3.6 Access

Access to corporate records may be requested by Trust staff or external

individuals/ organisations. Whilst internal requests have to be recorded bythe relevant operational unit in accordance with its retrieval and trackingsystem, external requests are to be delegated to the Freedom ofInformation Co-ordinator.

3.7 Appraisal

3.7.1 Appraisal is the term used for the assessment of the value of records. Anappraisal is usually a two-part decision making process. The first part is

deciding how long a record needs to be kept and the second part isdeciding whether a record can be disposed of or whether it needs to bearchived.

3.7.2 Records have two main types of value: A primary, or business value and asecondary , or value to the society. It is usually the records primary valuewhich determines how long a record should be kept, unless the record alsohas a secondary value.

3.7.3 The evaluation of records and the decision as to whether a record shouldbe archived or disposed of falls onto the Record Manager of eachoperational unit. All Record Managers have to ensure that their records areannually appraised. Appraisals should not be carried out at the level of theindividual record but at the level of record series or record group. Thisensures consistency and also cuts down on the time and resourcesneeded for appraisals.

3.7.4 Appendix A shows a typical thought tree that may be used during theappraisal process. However, each operational unit may decide to considerfurther questions during the appraisal.

3.7.5 Electronic records should be appraised using the same criteria andmethodologies as for paper records, but given that electronic records are


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3.8.2 Irrespective of the aforementioned Retention Schedule, the general rule isthat records should not ordinarily be retained for more than 30 years.

3.8.3 Records selected for archival preservation should be transferred as soonas possible to an archival institution that has adequate storage and publicaccess facilities.

3.8.4 Records selected for destruction should be destroyed in as a securemanner as is appropriate having regard to the level of confidentiality andprotective markings they bear (see Guidance for Classification Marking ofNHS Information). Where records are destroyed on site, a record of thedestruction including the reference, description and date of destructionshould be maintained and preserved by the responsible Record Manager.

3.8.5 If records are sent to an authorised contractor, employed for thedestruction, the contractor should be required to sign confidentialityundertakings and to produce a written certification as proof of thedestruction.

4 Duties

4.1 The duties of the Chief Executive, Director of Corporate Affairs and LocalRecord Managers are set out in the Record Management Policy.

4.2 Designated members of staff have lead responsibility in relation to thefollowing records:

Director of Human Resources for personnel records,

Head of Finance for financial records,

Commercial Director for salaries and wage records,

Head of Procurement for supply and purchase records,

Director of ICT for electronic storage of records,

Director of Corporate Affairs for policies and procedures, professionalreviews and reports, internal and external audits, risk assessments, etc

Line Managers for monitoring and training in local areas.

4.3 All Trust staff, whether clinical or administrative, who create, receive, use,


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5.1.2 All training has to be evaluated and reviewed on an annual basis by theTraining and Development Manager.

5.2 Audit

5.2.1 A number of bodies external to the Trust currently undertake reviews thatinclude assessment of some elements of Records management againstspecific standards. These include the Healthcare Commission, NHSLitigation Authority, Audit Commission and other bodies supporting orgoverning professional practice. Records audits may also be included inthe scope of an Internal or external audit plan agreed with the Board orAudit Committee.

5.2.2 Irrespective of the type of audit undertaken, or the body undertaking it, it isimportant that the officer assigned overall organisational responsibility forrecords management is aware of, or appraised of, the audits beforehand. Itis also important that this officer is informed of the audit outcomes and co-ordinates and reports significant findings to the Information GovernanceGroup or any supporting records management sub-group.

5.2.3 The Information Governance Group will be responsible for establishing aregular programme of audit for records management and for reportingupdates to the Board on the progress of this, including any significantareas of non-compliance.

6. ReferencesRecords Management Society, Toolkit for Managing Paper Records Version 1, available from: http://www.rms-gb.org.uk

Department of Health, NHS Code of Practice 2, Annex 2D, available from:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance

Connecting for Health, Corporate Records Management, available from:http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/records

7. Associated Controlled Documents
http://www.rms-gb.org.uk/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidancehttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidancehttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidancehttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidancehttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidancehttp://www.rms-gb.org.uk/


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Data Protection Policy

Emergency Preparedness and Business Continuity Policy Email Policy


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Append ix A

Guideline Naming Convention

This Appendix sets out guidelines in relation to the naming conventions tobe developed by each operational unit. The guidelines are divided into 13basic rules which should be followed wherever possible.

Rule 1: Use short but meaningful names

File names should be kept as short as possible whilst also beingmeaningful. Long file names mean long file paths and long URLs which

increase the likelihood of error. They are more difficult to remember andrecognise, and are more difficult to transmit in emails as they often break.However, avoid using initials, abbreviations and codes that are notcommonly understood.

Rule 1 Example

Correct Incorrect

File name SausageMashCtteeRemit.rtf

The_sausage_and_mash_committee_remit.rtf

Explanation

Some words add length to a file name but do not contributetowards the meaning, for example words like the, a, and and.Where the remaining file name is still meaningful within the contextof the file directory these elements can be removed. Sometimeswords have standard abbreviations, e.g. cttee is a standardabbreviation for committee; where this is the case the standardabbreviation can be used.

Rule 2:Avoiding unnecessary repet it ion and redundancy

Avoid redundancy in file names and file paths. Unnecessary repetitionincreases the length of file names and file paths, which is incompatible withrule 1.

Rule 2 Example

Correct Incorrect

File name/.../Court/20041030Minutes.rtf

/.../Court/20041030CourtMinutes.rtf/ /Procedures/Ap
http://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule02.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule02.htm


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Append ix A

procedures document. If two-digit numbers are used the latestversion will always be at the bottom of the list.

Rule 5: Use dates back to front

If using a date in the file name always state the date back to front, anduse four digit years, two digit months and two digit days: YYYYMMDD .

Dates should always be presented back to front, that is with the year first(always given as a four digit number), followed by the month (always givenas a two digit number), and the day (always given as a two digit number).Giving the dates back to front means that the chronological order of theRecords is maintained when the file names are listed in the file directory.This helps when trying to retrieve the latest dated Record.

Rule 5 Example

Correct Incorrect

File name

20040324Agenda.rtf20040324Minutes.rtf20040324PaperA.rtf20050201Agenda.rtf20050201Minutes.rtf

(Orderedalphanumerically asthe files would be in

the directory list)

1Feb2005Agenda.rtf1Feb2005Minutes.rtf24March2004Agenda.rtf24March2004Minutes.rtf24March2004PaperA.rtf

(Orderedalphanumerically as thefiles would be in the

directory list)

ExplanationThis example shows the minutes and papers of a committee. Bystating the year back to front the minutes and papers from themost recent meeting appear at the bottom of the directory list.

Rule 6: Use family names rather than Christ ian names

When including a personal name in a file name, use the family name firstfollowed by the initials.It may be appropriate to include within a file namethe name of an individual, usually when the record is a piece ofcorrespondence. However, it will not usually be appropriate to name

d ft th d t i id i d ft
http://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule05.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule05.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule05.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule05.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule06.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule06.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule06.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule06.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule05.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule05.htm


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Append ix A

Rule 7: Avoid using common words

Avoid using common words such as draft or letter at the start of filenames, or all of those records will appear together in the file directory,making it more difficult to retrieve the records you are looking for.

You may only ignore this rule if starting file names with these sorts ofwords aids the retrieval of the records. See rule 8 for further details.

Rule 7 Example

Correct Incorrect

File name

//Publicity/AdvertisingV01Draft.rtfAdvertisingV05Final.rtfBudgetReport2002-2003V20Final.rtf

BudgetReport2003-2004V15Draft.rtfGrantS20040312.rtfOfficeProceduresV10Draft.rtfThomasA20031205.rtf

(Ordered alphanumericallyas the files would be in thedirectory list)

//Publicity/DraftAdvertising.rtfDraftBudgetReport2003-2004.rtfDraftOfficeProcedures.rtf

FinalAdvertising.rtfFinalBudgetReport2002-2003.rtfLetterAThomas.rtfLetterSGrant.rtf

(Orderedalphanumerically as thefiles would be in thedirectory list)

Explanation

The file directory will list files in alphanumeric order. This means that allRecords with file names starting Draft will be listed together. Whenretrieving files it will be more useful to find the draft budget report nextto the previous years budget, rather than next to an unrelated draftRecord.

Rule 8: Order the dif ferent elements in a file name in a logical way

The elements to be included in a file name should be ordered according tothe way in which the record will be retrieved during the course of every daybusiness. This will depend on the way you work. For example, if therecords are retrieved according to their date, the date element shouldappear first If the records are retrieved according to their description the


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Append ix A

WeddingDinner20030304.rtf

(Ordered alphabetically as the

files would be in the directorylist)

20040905ProcurementAward.rtf

(Ordered alphabeticallyas the files would be inthe directory list)

Explanation

The first example shows minutes and agenda of the SausageCommittee. Minutes and papers of a meeting are likely to beretrieved on the basis of the date of the meeting, it is thereforebest to have the date at the start of the file name, otherwise allthe Agendas will come at the top of the directory list, followed byall of the minutes, and then by the papers.

The second example shows the file names of the files in theEvents folder. Because events are likely to be retrieved by thename of the event rather than the date of the event, it is mostuseful to have that element first.

Rule 9: Record recurring events both by date and event name/subjectmatter

The file names of records relating to recurring events (e.g. meetingminutes and papers, weekly, monthly or annual reports, eventmanagement and budget planning documents) should include both thedate and the event name or event description so that the record can beidentified and retrieved.

When deciding the order of the elements consider rule 8. Date first willusually be appropriate for events that are time specific and recurring. Eventfirst will usually be appropriate for events that are infrequent, but regularlyrecurring.

The event description could be the title of the event or the subject of theevent, whatever description you choose, ensure that it is short, to the point,and readily recognisable to you and the colleagues you work with.

Rule 9 Example

Correct Incorrect

//Website/20040301WebStats rtf

//Website/WebStats20040301.rtf


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Append ix A

appropriate for the folder to be called WebStats, in which casethe file names only need to include the date. For anotherexample see the first rule 8 example.

The second example shows annual budget reports. Because thereports are annual and likely to be retrieved by the descriptionrather than the date, it is likely that it will be most appropriate forthe description element to come first. Also remember rule 2; insome cases it may be appropriate for the folder to be calledPlanning2003-2004, in which case the file names only need toinclude a description. For another example see the second rule 8example.

Rule 10: Use name of correspondent, subject description, date and rcvd when Recording correspondence

The file names of correspondence should include the following elementsso that the record can be easily identified and retrieved:

Name of correspondent, that is the either the name of the person who sentyou the letter/email/memo or the name of the person to whom you sent theletter/email/memo

Subject description, where it is not given in the folder title Date of letter/email/memo If incoming correspondence, include rcvd

When deciding the order of the elements consider rule 8. It will usually beappropriate to order the elements in the same order in which they are listedabove, as it is likely that correspondence will be retrieved on the basis ofthe correspondent. Also consider rule 2; a description of the subject mayalready be given in the folder name.

The sender is responsible for filing correspondence and any attachmentsor enclosures, except when the correspondence originates from outsidethe University, when the first named recipient is responsible for filing thecorrespondence and any attachments or enclosures.

If more than one email is received from the same person, on the same day,on the same subject and the latest email does not include the whole string


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Append ix A

shared drive, the documents will need to be saved separately, but the filenames should provide a cross reference between them; rule 11 should be

used for the attachment and rule 10 should be used for the email.

The file names of attachments that have been received should include thefollowing elements so that the context of the record is maintained:

Name of correspondent - to link the attachment with the covering email thisshould be the same as the file name on the email

Subject description - to link the attachment with the covering email thisshould be the same as the file name on the email

Date of email - to link the attachmentwith the covering email this should bethe same as the file name on the email

'attch' - to indicate the document is an attachment [2 digit number] of [2 digit number] - to indicate the number of attachments

received with the same covering email

When deciding the order of the elements consider rule 8. It will usually beappropriate to order the elements in the same order in which they are listedabove, as it is likely that the email and its attachment will be retrievedaccording to the correspondent. Also consider rule 2; a description of thesubject may already be given in the folder name.

Rule 11 Example

Correct Incorrect

//Complaints/BloggsJ20031205attch01of02.pdfBloggsJ20031205attch02of02.pdfBloggsJ20031205rcvd.txtBloggsJ20040105.rtfBloggsJ20040220.rtfThomasH20030610attch01of01.rtfThomasH20030610rcvd.txtThomasH20030710.rtf

(Ordered alphanumerically as the fileswould be in the directory list)

//Complaints/AttachmentFromHThomas10Jun03.rtfAttachment1FromJBloggs.pdfAttachment2FromJBloggs.pdfEmailFromHelenThomas10Jun03.txtEmailToJoeBloggs5Dec03.txtLetterFromJoeBloggs5Jan04.rtfLetterToHelenThomas10Jul03.rtf

LetterToJoeBloggs20Feb04.rtf

(Ordered alphanumerically as thefiles would be in the directory list)

This example shows the incoming and outgoing correspondence concerning


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Append ix A

Rule 12: Use version numbers followed by DRAFT or FINAL

The version number of a record should be indicated in its file name by theinclusion of V followed by the version number and, where applicable,Draft.

Some records go through a number of versions, for example they start outas working drafts, become consultation drafts and finish with a final draft,which may then be reviewed and updated at a later date. It is important tobe able to differentiate between these various drafts by giving them eachtheir own number.

Where a version number is applicable, it should always appear in the filename of the record so that the most recent version can be easily identifiedand retrieved.

Rule 12 Example

Correct Incorrect

File name

IEAM2003-2004V03Draft.htmIEAM2003-2004V04Final.htmOrgHier2002V02.xlsOrgHier2002V03.xls

OrgHier2002V04.xls

Iemodel0304_draftv3.htmIemodle0304_finalv4htmOrg_Hier_2002_v2.xlsOrg_Hier_2002_v3.xlsOrg_Hier_2002_v4.xls

Explanation

The first example shows two versions of the income andexpenditure attribution model for 2003-2004, version 3 is a draftversion and version 4 is the final version. The common abbreviationfor the model is used. The covering years are given in four-digitformat. The version number is given with two digits so that theversions will appear in numeric order.

The second example shows a number of versions of theorganisational hierarchy for 2002. In this case none of the versions

are marked as draft or final because the nature of the Recordmeans that draft and final are not applicable.

Rule 13: Avoid using non-alphanumeric characters
http://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule12.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule12.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule12.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule13.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule13.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule12.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule12.htmhttp://www.recordsmanagement.ed.ac.uk/InfoStaff/RMstaff/RMprojects/PP/FileNameRules/Rule12.htm


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Append ix B

Typical thought t ree

YesIs there a statutory requirement

to keep these Records?(If unsure, check the corporate

retention schedule)

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

N

Does the Record contain

information which either has beenor is likely to be needed to defend

a legal case?

Are there any acceptedstandards/best practice notes to

follow?

Is the Record a draft of a reportthat has not yet been issued?

Is the Record required for anaudit trail? (e.g. financial

document)

Does the Record contain coreinformation which forms part of a

larger project?


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Appendix C

Business and Corporate (Non-Health) Records Retention Schedule

This retention schedule details a Minimum Retention Period for each type of corporate

Record. Records (whatever the media) may be retained for longer than the minimum

period. However, Records should not ordinarily be retained for more than 30 years. The

National Archives (see Note below) should be consulted where a longer period than 30

years is required, or for any pre-1948 Records. Organisations should also remember

that Records containing personal information are subject to the Data Protection Act

1998.

The following types of Record are covered bythis retention schedule (regardless of the

media on which they are held, including paper, electronic, images and sound):

administrative Records (including personnel, estates, financial and accounting

Records, and notes associated with complaint handling);

photographs, slides and other images (non-clinical);

microform (ie microfiche/microfilm);

audio and video tapes, cassettes, CD-ROMs, etc;

e-mails;

computerised Records; and

scanned documents

The schedule is split into the following types of Records:

Administrative (corporate and organisation)

Biomedical Engineering

Estates/engineeringFinancial

IM & T

Other

Personnel/human resources


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Appendix C

Procedure for the Management of Corporate Records Issued: 14/04/2010Document Control Number: 469 22 of 65 Version No: 1

TYPE/SUBTYPE OF RECORD MINIMUM RETENTION PERIOD DERIVATION FINALACTION

CODE

ADMINISTRATIVE (CORPORATE AND

ORGANISATION)

Accident forms (see also Litigation dossiers) 10 years Destroy under

confidentialconditions

S

Accident register (Reporting of Injuries,

Diseases and Dangerous

Occurrencesregister) see also Incident

forms

10 years Reporting of Injuries,

Diseases and Dangerous

Occurrences Regulations

(reg. 7); SocialSecurity(Claims and Payments)

Regulations (reg. 25)

Destroy under

confidential

conditions

C

Adoption Records

(i.e. administrative Records relating the

adoption process)

75th anniversary of the date of birth of

the child to whom it relates or, if the

child dies before attaining the age of

18,15 years beginning with thedate of

the 18th birthday

Children and Young Persons

Arrangements for Placement

of Children (General)

(Regulations 1991,SI 1991,

No. 890 regs. 8, 9, 10

childrens Records) Adoption

Regulations 2004(reg. 34)

Destroy under

confidential

conditions

N


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Appendix C



CODE

Advance letters (eg DH guidance) 6 years Destroy S

Agendas of board meetings, committees,

sub-committees (master copies,including

associated papers)

30 years See note 1 S

Agendas (other) 2 years Destroy under

confidential

conditions

S

Agreements (see Contracts)

Ambulance Records Administrative (i.e.

Records containing non-clinical details only)

e.g. Records of journeys

2 years from the end of the year to

which they relate

Destroy under

confidential

conditions

N

Annual/corporate reports 3 years See note 1 S

Appointment Records (GP) 2 years (Provided that any patient- Destroy under N


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Appendix C



CODE

relevant information has been

transferred to the patient Record)

At the end of the 2 year retention

period GP practices should consider if

there is an ongoing administrative

need to keep the Records/books for

longer. If there IS an ongoing need toretain these Records/books, then a

further review date should be set

(either 1 or 2 more years)

confidential

conditions

once a decision

has been made

that there is no

ongoing

administrativeneed to retain

the Records.

Assembly/Parliamentary questions,MP

enquiries

10 years As these

documents

include allinformation

provided by the

organisation in

response to a

PQ (e.g.

background note

to the Minister or

the Minster mayamend the

response) all of

which may not

be used in the

response and

S


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Appendix C



CODE

therefore it will

not be in the

public domain on

House of

Commons

Records they

must bedestroyed under

confidential

conditions.

Audit Records (e.g. Organisational Audits,

Records Audits, Systems Audits) Internal &External in any format (paper, electronic etc)

2 years from the date of completion of

the audit

Destroy under


N

Business plans, including local delivery plans 20 years Destroy S

Catering forms 6 years Destroy underconfidential

conditions

S

Close circuit TV images 31 days Information Commissioners Erase S


26/65

Appendix C



CODE

Code of Conduct permanently

Commissioning decisions

Appeal documentation

Decision documentation

6 years from date of appeal decision

6 years from date of decision

Destroy under

confidential

conditions

S

S

Complaints (See also litigation dossiers)

Correspondence, investigation and outcomes

Returns made to DH

8 years from completion of action

Files closed annually and kept for

6 years following closure

NB: Current policy on the handling of

complaints is under review and further

guidancewill be issued in due course

Destroy under

confidential

conditions

C

Copyright declaration forms

(Library Service)

6 years Copyright, Designs and

Patents Act 1988

Destroy under

confidential

conditions

N

Data Input Forms (where the data/information

has been input to a computer system)

2 years Destroy under

confidential

conditions

N

A di C


27/65

Appendix C



CODE

Diaries (office) 1 year after the end of the calendar

year to which they refer

Destroy under

confidential

conditions

S

Exposure monitoring Records 5 years from the date the Record was

made

Control of Substances

Hazardous to Health

Regulations 2002 (reg. 10(5))

Destroy under

confidential

conditions

S

Find-a-Doc Records (kept by PCTs)

contact sheets and letters

assignment cases/letters

Records of negotiations with GMS contract

managers re: patient registration with a

GP

6 months

2 years

2 years

Destroy under


N

Flexi working hours (personal Record ofhours actually worked)

6 months Destroy underconfidential

conditions

S

Freedom of Information requests 3 years after full disclosure; Destroy under S


28/65

Appendix C


29/65

Appendix C



CODE

conditions

Indices (Records management) Registry lists of public Records

marked for permanent preservation,

or containing the Record of

management of public Records 30years

File lists and document lists where

public Records or their management

are not covered 30 years

See note 1

Destroy under

confidential

conditions

S

S

Laundry lists and receipts 2 years from completion of audit Destroy under


S

Library registration forms 2 years after registration Destroy S

Litigation dossiers (complaints including

accident/incident reports)

Records/documents relating to anyform of

litigation

10 years

Where a legal action has commenced,

keep as advised by legal

representatives

Destroy under

confidential

conditions

S

S

Appendix C


30/65

Appendix C



CODE

Manuals policy and procedure

(administrative and clinical, strategy

documents)

10 years after life of the system (or

superseded) to which the policies or

procedures refer

Destroy (policy

documents may

have archival

value see note

1)

S

Maps Lifetime of the organisation See note 1 S

Meetings and minutes papers of major

committees and sub-committees

(master copies)


Meetings and minutes papers (other,

including reference copies of major

committees)


confidential

conditions

S

Mental Health Act Administration Records 5 years

NB There is no obligation to treat this

type of mental health Record as being

part of a patients health Record.

There may, however, be exceptions,

such as where they are required to be

HC(91)29 (NHS)

SI 2001/3869, reg.47

(Independent Sector)

Destroy under

confidential

conditions

N

Appendix C


31/65

Appendix C



CODE

kept as evidence in actual or

expected litigation or where they are

needed by a healthcare professional

in order to provide healthcare.

Each healthcare practitioner has

discretion as to the information which

s/he wishes to include as part of apatient Record. If in any particular

case a healthcare practitioner requires

a document which forms part of the

mental health act administration

Record to be included in a patients

Record (because he or she regards it

as relevant to the patients

healthcare), it should then be

regarded as part of the patient health

Record

Mortgage documents (acquisition, transfer

and disposal)

6 years after repayment See note 1 S

Nominal rolls 6 years (maximum) Destroy under

confidential

conditions

S

Appendix C


32/65

pp



CODE

Papers of minor or short-lived importance not

covered elsewhere, eg:

advertising matter

covering letters

reminders

letters making appointmentsanonymous or unintelligible letters

drafts

duplicates of documents known to be

preserved elsewhere (unless they have

important minutes on them)

indices and registers compiled for temporary

purposes

routine reports

punched cards

other documents that have ceased to be of

value on settlement of the matter involved

2 years after the settlement of the

matter to which they relate

Destroy under

confidential

conditions

S

Patient Advice & Liaison Service (PALS)Records

10 years after closure of the case Destroy underconfidential

conditions

N

Patient information leaflets 6 years after the leaflet has been See note 1 C

Appendix C


33/65

pp



CODE

superseded

Patients property books/registers (property

handed in for safekeeping)

6 years after the end of the financial

year in which the property was

disposed of or 6 years after the

register was closed

Destroy under

confidential

conditions

S

Patient Surveys (re access to services etc) 2 years Destroy under

confidential

conditions

N

Phone Message Books 2 years

NB Any clinical information should be

transferred to the patient health

Record

Destroy under

confidential

conditions

N

Police Statements (made in the context of

Accident and Emergency episodes.

Statements are requested by the Police to

the A&E staff in relation to alleged injuries of

or by patients coming through A&E)

10 years (congruent retention period

as Incident Forms)

Destroy under

confidential

conditions

N

Appendix C


34/65



CODE

Press cuttings 1 year Destroy (where

bound volumes

exist, see note 1)

S

Press Releases 7 years see note 1 N

Project files (over 100,000) on termination,

including abandoned or deferred projects


Project files (less than 100,000) on

termination


confidential

conditions

S

Project team files (summary retained) 3 years Destroy under

confidential

conditions

S

Public Consultations e.g. about future

provision of services


confidential

conditions

N

Appendix C


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CODE

Quality and Outcomes Framework (QOF)

documents (GP Practice Records)


confidential

conditions

N

Quality assurance Records (eg Healthcare

Commission, Audit Commission, Kings Fund

Organisational Audit, Investors in People)


confidential

conditions

S

Receipts for registered and Recorded mail 2 years following the end of the

financial year to which they relate

Destroy under


S

Records documenting the archiving, transfer

to public Records archive or destruction of

Records


Records of custody and transfer of keys 2 years after last entry Destroy under

confidential

conditions

S

Appendix C


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CODE

Reports (major) 30 years See note 1 S

Requests for access to Records, other than

Freedom of Information or subject accessrequests

6 years after last action Destroy under


S

Requisitions 18 months Destroy under

confidential

conditions

S

Research ethics committee Records 3 years from date of decision See note 1 C

Serious incident files 30 years See note 1 S

Specifications (eg equipment, services) 6 years Limitation Act 1980 Destroy under

confidential

conditions

S

Appendix C


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CODE

Statistics (including Korner returns, contract

minimum data set, statistical returns to DH,

patient activity)

3 years from date of submission Destroy S

Subject access requests (DPA and AHR)

Records of requests

3 years after last action Destroy under


S

Surgical appliances forms AP 1, 2, 3 and 4 2 years from completion of audit Destroy under

confidential

conditions

S

Time sheets (relating to a Group or

Department e.g. Ward where the timesheets

are kept as a tool to manage resources,

staffing levels)

6 months Destroy under

confidential

conditions

N

BIOMEDICAL ENGINEERING

Sterilix Endoscopic Disinfector Daily Water 11 years Consumer Protection Act Destroy under

confidential

N

Appendix C


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CODE

Cycle Test, 1987 conditions

Sterilix Endoscopic Disinfector Daily Water

Purge Test, Nynhydrin Test

11 years Consumer Protection Act

1987

Destroy under

confidential

conditions

N

ESTATES/ENGINEERING

Buildings and engineering works, including

major projects abandoned or deferred key

Records (eg final accounts, surveys, site

plans, bills of quantities)


Buildings and engineering works, including

major projects abandoned or deferred town

and country planning matters and all formal

contract documents (eg executed

agreements, conditions of contract,

specifications, as built Record drawings,

documents on the appointment and

conditions of engagement of private buildings

and engineering consultants)


Appendix C


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CODE

Buildings papers relating to occupation of

the building (but not health and safety

information)

3 years after occupation ceases Construction Design

Management Regulations

1994

Destroy under

confidential

conditions

S

Deeds of title Retain while the organisation has

ownership of the building unless a

Land Registry certificate has been

issued, in which case the deeds

should be placed in an archive

If there is no Land Registry certificate,

the deeds should pass on with thesale of the building

See note 1 S

Drawings plans and buildings (architect

signed, not copies)

Lifetime of the building to which they

relate

See note 1 S

Engineering works plans and buildingRecords

Lifetime of the building to which theyrelate

See note 1 S

Equipment Records of non-fixed

equipment, including specification, test

11 years

If the Records relate to vehicles

Consumer Protection Act

1987

Destroy under

confidential

N

Appendix C


40/65

Procedure for the Management of Corporate Records Issued: 14/04/2010

Document Control Number: 469 40 of 65 Version No: 1


CODE

Records, maintenance Records and logs (ambulances, responder cars, fleet

vehicles etc) and where the vehicle no

longer exists, providing there is a

Record that it was scrapped, the

Records can be destroyed

conditions

Inspection reports (eg boilers, lifts) Lifetime of installation

If there is any measurable risk of a

liability in respect of installations

beyond their operational lives, the

Records should be retained

indefinitely

See note 1 S

Inventories of furniture, medical and surgical

equipment not held on store charge and with

a minimum life of 5 years

Keep until next inventory See note 1 C

Inventories of plant and permanent or fixed

equipment

5 years after date of inventory See note 1 S

Land surveys/registers 30 years See note 1 S

Leases the grant of leases, licences and Period of the lease plus 12 years Limitation Act 1980 Destroy under S


41/65

Appendix C


42/65




CODE

Plans building (detailed) Lifetime of building May have

historical value

(see note 1)

S

Plans engineering Lifetime of building See note 1 S

Property acquisitions dossiers 30 years See note 1 S

Property disposal dossiers 30 years See note 1 S

Radioactive waste 30 years Radioactive Substances Act

1993

See note 1 S

Site files Lifetime of site See note 1 S

Structure plans (organisational charts) i.e. the

structure of the building plans

Lifetime of building See note 1 C


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Appendix C


44/65




CODE

Advice notes (payment) 1.5 years Destroy under

confidential

conditions

S

Audit Records (internal and external audit)

original documents

2 years from completion of audit Destroy under


N

Audit reports internal and external

(including management letters, value for

money reports and system/final accounts

memoranda)

2 years after formal completion by

statutory auditor

Destroy under

confidential

conditions

N

Bank statements 2 years from completion of audit Destroy under

confidential

conditions

S

Banks Automated Clearing System (BACS)

Records

6 years after year end Destroy under

confidential

conditions

S

Appendix C


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CODE

Benefactions (Records of) 5 years after end of financial year in

which the trust monies become finally

spent or the gift in kind is accepted. In

cases where the Benefaction

Endowment Trust fund/capital/interest

remains permanent,Records should

be permanently retained by the

organisation

See note 1 S

Bills, receipts and cleared cheques 6 years Destroy under

confidential

conditions

S

Budgets (including working papers, reports,

virements and journals)

2 years from completion of audit Destroy under

confidential

conditions

S

Capital charges data 2 years from completion of audit Destroy underconfidential

conditions

S

Capital paid invoices (see Invoices)

Appendix C


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CODE

Cash books 6 years after end of financial year to

which they relate

Limitation Act 1980 Destroy under

confidential

conditions

S

Cash sheets 6 years after end of financial year to

which they relate


confidential

conditions

S

Contracts financial Approval files 15 years

Approved suppliers lists 11 years

Destroy under


C

Contracts non-sealed (property) on

termination

6 years after termination of contract Limitation Act 1980 Destroy under

confidential

conditions

S

Contracts non-sealed (other) on termination 6 years after termination of contract LimitationAct 1980 Destroy under

confidential

conditions

S

Appendix C


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CODE

Contracts sealed (and associated Records) Minimum of 15 years, after which they

should be reviewed

See note 1 S

Contractual arrangements with hospitals orother bodies outside the NHS, including

papers relating to financial settlements made

under the contract (eg waiting list initiative,

private finance initiative)

6 years after end of financial year towhich they relate

Destroy underconfidential

conditions

S

Cost accounts 3 years after end of financial year towhich they relate


conditions

S

Creditor payments 3 years after end of financial year to

which they relate

Destroy under

confidential

conditions

S

Debtors Records cleared 2 years from completion of audit Destroy under

confidential

conditions

S

Appendix C


48/65




CODE

Debtors Records uncleared 6 years from completion of audit Destroy under

confidential

conditions

S

Demand notes 6 years after end of financial year to

which they relate

Destroy under

confidential

conditions

S

Estimates, including supporting calculations

and statistics

3 years after end of financial year to

which they relate

Destroy under


S

Excess fares 2 years after end of financial year to

which they relate

Destroy under

confidential

conditions

S

Expense claims, including travel and

subsistence claims, and claims and

authorisations

5 years after end of financial year to

which they relate

Destroy under

confidential

conditions

S


49/65


50/65

Appendix C


51/65




CODE

PAYE Records 6 years after termination of

employment

Destroy under

confidential

conditions

S

Payments 6 years after year end Destroy under


S

Payroll (ie list of staff in the pay of the

organisation)

6 years after termination of

employment

Destroy under

confidential

conditions

Forsuperannuation

purposes,

organisations

may wish to

retain such

Records until the

subject reaches

benefit age

S

Positive predictive value performance

indicators


confidential

conditions

S

Appendix C


52/65




CODE

Private Finance Initiative (PFI) 30 years See note 1 S

Receipts 6 years after end of financial year to

which they relate



S

Salaries (see Wages)

Superannuation accounts 10 years Destroy underconfidential

conditions

S

Superannuation registers 10 years Destroy under

confidential

conditions

S

Tax forms 6 years Destroy under

confidential

S

Appendix C


53/65




CODE

conditions

Transport (staff pool car documentation) 3 years unless litigation ensues Destroy under

confidential

conditions

S

Trust documents without permanent

relevance/not otherwise mentioned


confidential

conditions

S

Trusts administered by StrategicHealthAuthorities (terms of)


VAT Records 6 years after end of financial year to

which they relate

Destroy under

confidential

conditions

S

Wages/salary Records 10 years after termination of

employment

Destroy under

confidential

conditions

S

Appendix C


54/65




CODE

For

superannuation

purposes,

organisations

may wish to

retain such

Records until the

subject reachesbenefit age.

IM & T

Documentation relating to computer

programmes written in-house

Lifetime of software Destroy under

confidential

conditions

S

Software licences Lifetime of software Destroy under

confidential

conditions

S

OTHER

Appendix C

TYPE/SUBTYPE OF RECORD MINIMUM RETENTION PERIOD DERIVATION FINAL CODE


55/65




CODE

Chaplaincy Records 2 years May have

archival value

see note 1

S

Contractor Applications (Doctors, Dentists,

Opticians & Pharmacists)

6 years after end of contract for

approvals

6 years for non-approvals.

Destroy under

confidential

conditions

N

Contractor Records

(e.g. Ophthalmic Opticians, Ophthalmic

Medical Practitioners, Pharmacists,

Pharmacy Premises, General Optical Councilamendments to the register, Previous

Pharmacy rotas and supporting information

(prior to 2005 new regulations), Copies of

previous Pharmacy and Ophthalmic local

lists, Correspondence relating to pharmacies

supplying oxygen and visiting

Residential/Nursing homes (prior to new

regulations)

7 years NHS(General Ophthalmic

Services) Regs 1986:

A contractor shall keep a

proper Record in respect ofeach patient to whom he

provides general ophthalmic

services, giving appropriate

details of sight testing.

Subject to paragraph 8(5) a

contractor shall retain all such

Records for a period of sevenyears, and shall during that

period produce them when

required to do so by a Primary

Care Trust or the Secretary of

State.

Destroy under

confidential

conditions

N

Appendix C



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CODE

Follow link below for more

detail

http://www.dh.gov.uk/assetRo

ot/04/10/12/ 42/04101242.pdf

Doctors Postgraduate Educational

Allowance/ Personal Development Plan files

and supporting general correspondence

Records kept by PCTs

GP Seniority (prior to 2004 new

regulations)

NHS(General Ophthalmic

Services) Regs 1986:

A contractor shall keep a

proper Record in respect of

each patient to whom he

provides general ophthalmic

services, giving appropriate

details of sight testing.

Subject to paragraph 8(5) acontractor shall retain all such

Records for a period of seven

years, and shall during that

period produce them when

required to do so by a Primary

Care Trust or the Secretary of

State.

Follow link below for more

detail


ot/04/10/12/ 42/04101242.pdf

Destroy under

confidential

conditions

N

Appendix C



57/65




CODE

Family Health Service Appeals Authority

tribunal and case files

Case files 10 years

Decision Records until individuals

80th birthday

See note 1

Destroy under

confidential

conditions

S

GP retirements/moved away 6 years after individual leaves service,

at which time a summary of the file

must be kept until the individuals 70th

birthday

See note 1 N

Research and development (organisation)

i.e. all the organisations Records associated

with research and development and notindividual trial Records or information on

patients.

30 years Medical Research Council See note 1 N

PERSONNEL/HUMAN RESOURCES

NB Both medical staff Records and agency

locums staff Records should be treated aspersonnel Records and retained accordingly.

Consultants (Records relating to the

recruitment of)

5 years NHS (Appointment of

Consultants) Regulations,

Destroy under

confidential

S

Appendix C



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CODE

good practice guidelines,

page 11, para. 5.3


ot/04/10/27/ 50/04102750.pdf

conditions

CVs for non-executive directors (successful

applicants)

5 years following term of office Destroy under

confidential

conditions

S

CVs for non-executive directors

(unsuccessful applicants)


confidential

conditions

S

Duty rosters

i.e. organisation or departmental rosters, not

the ones held on the individuals Record.

4 years after the year to which they

relate

Destroy under

confidential

conditions

N

Industrial relations (not routine staff matters),

including industrial tribunals


confidential

conditions

S


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Appendix C



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/SU O CO U O O OACTION

CO

annual leave Records, duty rosters,

clock cards, timesheets, study leave

applications, training plans

include periods of up to 6

years or more prior to the

claim and where evidence

could be needed from a

number of sources, it is

appropriate to retain as

much as possible from the

original file.

Letters of appointment 6 years after employment has

terminated or until 70th birthday,

whichever is later

Destroy under

confidential

conditions

S

Nurse training Records (from hospital-based

nurse training schools prior to the

introduction of academic-based training)

30 years See note 1 N

Pension Forms (all) 7 years HMRC Technical Pension

Notes for registered pension

schemes under regulation 18

of SI2006/567

RPSM12300020 Scheme

Adminstrator Information

Requirements and

Destroy under

confidential

conditions

N

Appendix C



61/65



ACTION

Adminstration for General

Retention of Records

Personnel/human resources Records major

(eg personal files, letters of appointment,

contracts, references and related

correspondence, registration authority forms,

training Records, equal opportunity

monitoring forms (if retained))

NB Includes locum doctors

6 years after individual leaves service,

at which time a summary of the file

must be kept until the individuals 70th

birthday

Summary to be retained until

individuals 70th birthday or until 6

years after cessation of employment if

aged over 70 years at the time.

The summary should contain

everything except attendance books,annual leave Records, duty rosters,

clock cards, timesheets, study leave

applications, training plans

The 6 year retention period is

to take into account any ET

claims, or EL claims that may

arise after the employee

leaves NHS employment,

requests for information from

the NHS pensions agency etc.

Claims of this nature can

include periods of up to 6

years or more prior to the

claim and where evidencecould be needed from a

number of sources, it is

appropriate to retain as

much as possible from the

original file.

See note 1 N

Personnel/human resources Records minor

(eg attendance books, annual leave Records,

duty rosters (i.e. duty rosters held on the

individuals Record not the organisation or

departmental rosters), clock cards,

2 years after the year to which they

relate

Destroy under

confidential

conditions

N

Appendix C



62/65



ACTION

timesheets (relating to individual staff

members))

NB Includes locum doctors

Staff car parking permits 3 years Destroy under

confidential

conditions

S

Study leave applications 5 years Destroy under

confidential

conditions

S

Timesheets (for individual members of staff) 2 years after the year to which they

relate

NB Timesheets (for all individuals

including locum doctors) held on the

personnel Record are minor Records

retain for 2 years.

Timesheets held elsewhere i.e. onthe ward retain for 6 months (as the

master timesheet is held on the

personnel file)

Destroy under

confidential

conditions

N

Appendix C

TYPE/SUBTYPE OF RECORD MINIMUM RETENTION PERIOD DERIVATION FINALC O

CODE


63/65



ACTION

Training plans 2 years Destroy under

confidential

conditions

S

PURCHASING/SUPPLIES

Approval files (contracts) 6 years after end of the year the

contract expired

Destroy under

confidential

conditions

S

Approved suppliers lists 11 years Consumer Protection Act1987


conditions

S

Delivery notes 2 years after end of financial year to

which they relate

Destroy under

confidential

conditions

S

Products (liability) 11 years Consumer Protection Act

1987

Destroy under

confidential

S

Appendix C


CODE


64/65



ACTION

conditions

Stock control reports 18 months Destroy under

confidential

conditions

S

Stores Records major (eg stores ledgers) 6 years Destroy under

confidential

conditions

S

Stores Records minor (eg requisitions,issue notes, transfer vouchers, goods

received books)

18 months Destroy underconfidential

conditions

S

Supplies Records minor (eg invitations to

tender and inadmissible tenders, routine

papers relating to catering and demands forfurniture, equipment, stationery and other

supplies)

18 months Destroy under

confidential

conditions

S

Appendix C


CODE


65/65



ACTION

Tenders (successful) Tender period plus 6 year limitation

period


confidential

conditions

S

Tenders (unsuccessful) 6 years Limitation Act 1980 Destroy under

confidential

conditions

S

Corporate Records Procedure

Documents

Transcript of Corporate Records Procedure