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Records Management Code of Practice for Health and Social Care

The latest version of the Records Management Code of Practice for Health and Social Care, published on 16 August 2024, is available via the links below:

Previous iterations of the Code of Practice are available via the following links:

What is the Code of Practice?

The Records Management Code of Practice for Health and Social Care (the ‘Code of Practice’) is a guide to the required standards when managing data, information and records.

It is based on current legal requirements and professional best practice. It aims to harmonise the management of data, information, and records across organisations to promote consistency of approach and support the ‘Once for Scotland’ ethos. We have developed the updated Code of Practice in collaboration with a wide range of stakeholders including NHS staff, clinicians, royal colleges, professional bodies, and trade unions to ensure that it is as comprehensive, relevant, and as useful as possible.

Ensuring that records are appropriately managed can:

  • increase efficiency and effectiveness, delivering savings in administration costs;
  • minimise unnecessary physical or digital information storage costs;
  • support clinical and business decision-making;
  • enhance, improve and develop service delivery;
  • support the achievement of business objectives and targets;
  • ensure compliance with legislation, regulations and standards;
  • support transparency;
  • underpin business resilience.

Who is the Code of Practice relevant to?

The Code of Practice sets out the standards for managing data, information and records for those who work within, or under contract to, NHS organisations in Scotland. It is aimed at any professional working within these organisations. However, where the following roles are in place in an organisation, it is particularly relevant to:

  • Corporate Records Managers,
  • Health Records Managers,
  • Records Management Leads,
  • Caldicott Guardians,
  • Data Protection Officers,
  • Information Governance Leads,
  • Senior Information Risk Owners.

History of the Code of Practice

The Scottish Government has been issuing guidance and letters to the NHS on the management of records since 1958. You can find previous Scottish Government letters and Code of Practice versions as follows:

Key changes within the new Code of Practice

We have restructured and streamlined the Code of Practice, with a particular focus on the removal of duplicated and conflicting information. We have expanded key sections, for example on definitions, regulatory and legislative requirements, roles and responsibilities, to provide full coverage of these areas. There are at least 15 additional new sections within the document, with additional detail added to other sections. We have also made significant changes have also to the management of employee (staff) records, with the removal of the previous requirement to hold a summary record until the person would turn 75 years of age.

In particular, we have simplified the retention periods for patient health records and added retention periods specific to digital health records, which can be easily applied to digital systems.  Digital adult secondary care records should now be retained until three years after death, thus removing the previous document’s alternative retention period of ‘six years after last seen, whichever is shorter’. This will result in digital records being retained for longer than paper records, however, we feel this is justified given the feedback received from stakeholders.

During the consultation we also received feedback that the retention period for children’s health records was not entirely clear. We have therefore amended the guidance to state that health organisations should retain all children’s records until the age of 25 years, whether they are living or deceased. This was due to feedback from clinicians, as they feel that this would be helpful in the care and treatment of children who have been diagnosed with genetic conditions.

Of the 42 stakeholder responses received, 22 agreed with the changes to the retention period for adult and children’s records, four disagreed, and 16 did not answer or marked ‘N/A’ (Not Applicable).

Code of Practice review process 2022-2024

During 2022 to 2024 we engaged with organisations and groups to review the 2020 version and make the changes required to ensure that the guidance remains up to date and fully comprehensive.

We carried out the following engagement:

  • We organised a workshop with NHS Record Managers (as the current predominant users) to gather information on key areas of the document that were required to be updated to reflect current legislation and best practice from their perspective.
  • We contacted policy teams within Scottish Government to consider changes required from a legislative perspective to particular sections within the document, or the addition of new sections in light of new legislation.
  • We engaged with subject matter experts across the health and social care sector in Scotland on the current content that was relevant to their specialist area. Where appropriate, a presentation was provided at group meetings to outline the programme of work; and a paper outlining the current content and queries for consideration were provided to each group along with a feedback form.
  • We set up Short Life Working Groups (SLWGs), with the following remit:
    • Digital Records SLWG – to consider what content needed to be added to ensure that the document outlined those considerations that should be taken into account when digitising records, and to consider required changes to ensure it adequately covered digital records.
    • Integrated Care Record SLWG – to consider the content of the current version in relation to evolving integrated care records, to support the application of best practice standards and compliance with legislation.
    • Health Records SLWG – to consider the changes required to simplify the health records retention schedule, including removing duplicates and clarifying what the named record types refer to. The group also provided information to inform new adult, children’s and Allied Health Professional’s record sections.
  • We circulated a new draft of the Code of Practice to approximately 90 stakeholders, with a feedback form to collect their views and any suggested changes. We asked stakeholders about their overall opinion of the document as well as whether:
    • there were records that should be covered in the Code of Practice and were not
    • they had comments or suggested amendments to the text within sections 1 – 5
    • they had comments or suggested amendments to the Records Retention Schedule
    • they were in agreement with the changes made with regards to extending the retention period for adult records within digital systems, and all children’s records.
  • We received over 40 responses from a variety of stakeholders, including, but not limited to:
    • Scottish Government Policy Teams
    • NHS National Groups
    • NHS Boards
    • Local Government
    • Royal Colleges
    • Professional Bodies
    • Regulatory Bodies
    • Third Party Organisations.
  • We collated and reviewed all comments. Where comments were straightforward, we applied them to the draft document; and where a minimal amount of further engagement was required, we undertook this and applied further changes. Some changes were not applied, however, due to the requirement for extensive further engagement and consultation; we will, however, pick this up in next steps.
  • We produced a new, baseline version and published the updated Code of Practice on 16 August 2024.

Next steps

The version published in 2020 had been extended to cover the wider health and social care sector insofar as those working within local authorities who handled NHS data, information and records should ensure that it was managed in line with the standards set out in the Code of Practice. It provided new guidance on integrated care records, and referenced the joint working between health and social care throughout the document.

We have agreed with COSLA that this latest 2024 version will remain as an NHS/SG document that applies principally to NHS records (while acknowledging some nuances around integrated records and other specific areas as agreed). It will provide a baseline version that we will expand to cover social work and social care following further collaborative work with Local Government partners.

We have also recognised that the Code of Practice would benefit from including guidance on the following areas:

  • Artificial Intelligence
  • Digital preservation
  • Pharmacy records
  • Bloods Tissues and Cells records.

The aim will now be to publish any new content on a digitally dynamic platform. The structure of the digital platform will provide greater clarity on the applicability of certain sections of the Code of Practice to either the whole health and social care sector, or only certain areas of the sector.

The platform will:

  • promote and enhance the use of the guidance by making it easier to access and navigate
  • ensure the guidance is adaptable to change in a timely manner
  • facilitate a subject matter expert review process to ensure that the document remains up to date and relevant
  • enable flags and alerts to be added to certain content where further considerations require to be taken into account, e.g. Public Inquiry Do Not Destroy notices.

Alongside the introduction of the digital platform we will introduce a change management process.  This process will provide stakeholders with the opportunity to highlight changes on an ongoing basis and will provide assurance that the proposed change has been appropriately considered prior to being accepted.