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NHS Records Management

Guidance for access to health records requests

This guidance aims to assists NHS organisations in England, through the process of dealing with an access request in accordance with the relevant legislation and any subsequent considerations. The guidance covers legislation pertinent to accessing health records, such as:

  • Data Protection Act 1998
  • Access to Health Records Act 1990
  • Freedom of Information Act 2000
  • Access to Medical Reports Act 1988

Download Guidance for access to health records requests

A clinicians' guide to record standards - Gateway reference number: 10508

The Royal College of Physicians (RCP) in partnership with NHS Connecting for Health has developed standards for hospital patient records, approved by the Academy of Medical Royal Colleges. The standards will improve patient safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.

Please visit the RCP website for further details: http://www.rcplondon.ac.uk/projects/generic-standards-clinical-records

The standards are accompanied by a two-part clinicians' guide:

  • Part 1 - provides the background and context of the development of the RCP Health Informatics Unit's professional record keeping standards for the structure and content of medical records. Specifically the generic medical record keeping standards and the standards for admission, handover and discharge records.
  • Part 2 - includes the generic medical record keeping standards, and provides the standard headings and definitions of the hospital admission records, and handover and discharge communications.

Hard copies of both parts can be ordered via the Department of Health Publications Online page. You will need to register before ordering.

Please visit: http://www.orderline.dh.gov.uk/ecom_dh/public/home.jsf

Records Management Roadmap

The Records Management Roadmap contains a range of practical tools and guidance designed to support organisations in the implementation of an effective records management system in line with the principles contained in the Records Management: NHS Code of Practice.

The Roadmap comprises 'how to' materials in the form of templates and checklists to assist organisations in developing and implementing solid records management processes. It complements the guidance and knowledge-based materials in the Information Governance Toolkit.

The Roadmap is in electronic format only, available via this website, enabling speedy updates to be made when new material is produced. The release of the Roadmap will be phased. The current content includes guidance on:

Records Management: NHS Code of Practice

Visit NHS Codes of Practice and legal obligations for the 'Records Management: NHS Code of Practice'.

Training modules

The following records management modules are available in the IG Training Tool

  • Records Management and the NHS Code of Practice - Foundation
  • Records Management in the NHS - Practitioner
  • Access to Health Records - Practitioner
  • The importance of good clinical record keeping - Introductory
  • Record keeping standards for hospital inpatients - Foundation

Please visit the IG Training Tool

To view the speaker notes for the presentations (PPT files) whilst online, open the file, right click on the first slide, then in PowerPoint 2002 select "Speaker Notes", in PowerPoint 2003 select "Edit Slides".

Other guidance material may be added later.