Noble's Records

Summary

A request was made for details regarding medical records management, storage locations, and the MediViewer digital system at Noble's Hospital. The Department of Health and Social Care disclosed contact details for records management, confirmed onsite storage of archives, and outlined retention periods, but withheld the disaster recovery plan citing national security and health safety exemptions.

Key Facts

• Mrs Gaye Miller is the qualified Records Management staff member at Noble's Hospital.
• All archived medical records are stored onsite at Noble's Hospital, not by private contractors.
• Deceased patient paper records are archived no later than twelve months after death.
• Living patient records are maintained in the active library with parts archived based on capacity needs.
• The disaster recovery plan for the MediViewer system was withheld.

Data Disclosed

• 12 months
• 18 April 2017
• 15 May 2017
• 01624 656071
• IM84-711i

Exemptions Cited

• Section 28 (national security and defence)
• Section 36 (Health and Safety)

Original Request

Noble's Records… again

Data Tables (1)

Data Tables (reformatted)

Full Response Text

Department of Health and Social Care

Rheynn Slaynt as Kiarail y Theay

Page 1 of 4 FOIA/DHSC/rvsd/01

Chief Executive: Malcolm Couch

By email:

Freedom of Information Team Department of Health & Social Care Chief Executive’s Office Crookall House Demesne Road Douglas Isle of Man, IM1 3QA Tel: Email: Website: Date: FOI Reference: (01624) 642621 foi.dhsc@gov.im www.gov.im/dhsc 15 May 2017 IM84-711i

Dear REQUEST UNDER THE FREEDOM OF INFORMATION ACT 2015 (“the Act”) Thank you for your request to the Department of Health and Social Care, dated 18 April 2017 Your request You asked for: Question 01: “Provide the contact details of who in your hospital is qualified in Records Management?” Question 02: “Confirm whether archived medical records are stored in Nobles hospital or by private contractors?”
Question 03: “Provide the name of who stores Nobles hospital archived medical records for you (if this is the case) and where they are stored (IOM or U.K.)” Question 04: “Confirm when medical records for Nobles patients are classed as records that require archiving? What I mean by this is, how long are paper medical records held 'before' they are sent to be archived (retention dates etc)?” Question 05: “Provide the disaster recovery plan (drp) for the new digital health record system (MediViewer) which is mentioned in your current records retention policy” Question 06: “Provide the contact details of the manager who is in total charge of the new digital health record system (MediViewer)” Question 07: “Does Nobles hospital scan their own medical records? If yes, provide the scanning of medical records (or similar named document) policy and scanning of medical records quality assurance policy or procedure”

Page 2 of 4 FOIA/DHSC/rvsd/01 Question 08: “Is Nobles Hospital now using MediViewer? If yes, which wards, departments, areas are using this new system?”

Response to your request We are pleased to be able to provide a response to your request with answers to some of your questions; while our aim is to provide information whenever possible, in this instance we are unable to provide some of the information you have requested. The reasons and statutory exemption sections are shown as part of the corresponding answers below: Question 01: Provide the contact details of who in your hospital is qualified in Records Management? In response to Question 01 the Department can confirm that of those having received Records Management qualifications as authorised or recorded by the Department (i.e. not independently undertaken), one member of staff at Noble’s Hospital is qualified in Records Management; please see their contact details below: Mrs Gaye Miller, PGDip Records Management Head of Information and Records Management Department of Health & Social Care Chief Executive’s Office Crookall House Demesne Road

Douglas
Isle of Man IM1 3QA Tel: 01624 656071 Email: gaye.miller@gov.im

Question 02: Confirm whether archived medical records are stored in Nobles hospital or by private contractors?
In response to Question 02, the Department can confirm that all archived medical records are stored onsite at Noble’s Hospital. Question 03: Provide the name of who stores Nobles hospital archived medical records for you (if this is the case) and where they are stored (IOM or U.K.) In response to Question 03, the Department can confirm that all archived medical records are stored onsite at Noble’s Hospital. Question 04: Confirm when medical records for Nobles patients are classed as records that require archiving? What I mean by this is, how long are paper medical records held 'before' they are sent to be archived (retention dates etc)? In response to Question 04, the time paper medical records are held before archiving varies. A deceased patient’s paper records are sent to be archived no later than twelve months after the patient has passed away. The normal retention period applies.

Page 3 of 4 FOIA/DHSC/rvsd/01 A living patient’s paper records are maintained within the active library but may have parts of their records archived depending on the capacity needs of the active library. The normal retention period is applied to both the live paper record as well as any archived records. Question 05: Provide the disaster recovery plan (“DRP”) for the new digital health record system (MediViewer) which is mentioned in your current records retention policy While our aim is to provide information whenever possible, in this instance we are unable to provide the information you have requested in Question 05 because of exemptions under Section 28 (qualified exempt information pertaining to “national security and defence”), and Section 36 (qualified exempt information pertaining to “Health and Safety”) of the Act applies to that information.
As these exemptions are subject to the public interest test, the Department has also considered whether the public interest falling in favour of releasing or withholding the information. Having considered all the circumstances of the exemptions against this request, we believe the balance of public interest falls in favour of withholding the information exempt under section 28 and section 36. On behalf of the Department, the FOI Team apologises that on this occasion we have not been able to be of more assistance. Question 06: Provide the contact details of the manager who is in total charge of the new digital health record system (MediViewer) In response to Question 06, the Department can confirm that there is a Noble’s Digital Programme Board and as part of this programme, the Senior Officer Responsible for the Digital Health Records is the Medical Director, Dr Jugnu Mahajan.
Question 07: Does Noble’s Hospital scan their own medical records? If yes, provide the scanning of medical records (or similar named document) policy and scanning of medical records quality assurance policy or procedure In response to Question 07, the Department can confirm that Noble’s Hospital scans their own medical records; please see “Document Image Processing: Standard Operating Procedure” in Appendix 01. Question 08: Is Noble’s Hospital now using MediViewer? If yes, which wards, departments, areas are using this new system? In response to Question 08, the Department can confirm that the Medical Records Department and the Women’s and Children’s Division Antenatal Department are both using MediViewer. Your right to request a review
If you are unhappy with this response to your Freedom of Information request, you may ask us to carry out an internal review of the response, by completing a complaint form and submitting it electronically or by delivery/post to the FOI Co-ordinator, Department of Health & Social Care, Chief Executive’s Officer, Crookall House, Demesne Road, Douglas, Isle of Man, IM1 3QA. An electronic version and paper version of our complaint form can be found by going to our website www.gov.im/about-the-government/freedom-of-information/how-to- make-a-freedom-of-information-request/ .

Page 4 of 4 FOIA/DHSC/rvsd/01 Your review request should explain why you are dissatisfied with this response, and should be made as soon as practicable. We will respond as soon as the review has been concluded.
If you are not satisfied with the result of the review, you then have the right to appeal to the Information Commissioner for a decision on:

1. Whether we have responded to your request for information in accordance with Part 2 of the Freedom of Information Act; or
2. Whether we are justified in refusing to give you the information requested.
   In response to an application for review, the Information Commissioner may, at any time, attempt to resolve a matter by negotiation, conciliation, mediation or another form of alternative dispute resolution and will have regard to any outcome of this in making any subsequent decision.
   Further information about Freedom of Information requests can be found on the Information Commissioner’s website at: www.inforights.im/information-centre/freedom-of-information. Should you have any queries concerning this letter, please do not hesitate to contact us. Yours Sincerely

Freedom of Information Team Department of Health and Social Care

Nobles Hospital - Medical Records

Document Image Processing

Standard Operating Procedure

Nobles Hospital

Issue Date:

May 2004 Reviewed:

September 2004 Reviewed:

February 2014

Appendix 01 FOI IM84-711i

                               - 1 -

Contents

Key Operational Principles

Page 2 Selection of documents to be scanned

Page 3 Splitting files into PR1 & PR2

Page 3 Preparation of documents to be scanned

Page 4 Preparing the batch

Page 4 Batch Header Form

Page 5 Batch Header Form – directions

Page 5 Scanning

Page 6 Scanned document quality

Page 7 Issue of Certificate of Authenticity

Page 7 Daily Log Book

Page 7 Releasing of scanned batch

Page 7 Indexing document

Page 8 Indexation, completeness & accuracy

Page 8 File reconstruction

Page 9 Confirmation of exact reconstruction

Page 9 Scanned batchers flagged Page 9 Shredding

Page 10

                               - 2 -

Key Operational Principles

All PR1 records are returned to Library by close of business

 There must be no PR1 record in the Scanning Bureau overnight as access to records is required at all times.
 Consequently splitting / scanning to be arranged such that all files that were selected and transferred in the daily workload are either fully processed and Quality Control checks completed or untouched and transferred back to the Library.
 The timetables for the Bureau staff and Medical Records staff must be co-ordinated to allow unprocessed files to be tracked back to the Library.

Quality Control is the essence of the process

 Only PR2 documents are being scanned, PR1 documents are to be left in the record, unless authorisation has been granted by a Consultant.  As the PR2 (paper) will be destroyed after scanning there is no recourse to rectify errors or omission.

Identification of Rogue Documents

 A Rogue Document is one that has been filed incorrectly either as a document in the wrong set of notes or a PR1 document in with PR2 documents or a PR2 document in with the PR1 documents. It is noted that the prime responsibility for correct filing lies with the person filing the document in the first instance. Nonetheless, at certain stages, the record will be reviewed to ensure that no Rogue Documents are present –

Splitting -> Scanning;
Scanning -> Indexing

Note – if a document is found belonging to someone else, it may not necessarily be a Rogue document as it may relate to the Patient’s treatment e.g. semen analysis for infertility or cytogenetic results for a child born with a genetic disorder.  If a Rogue Document is found, in the wrong set of notes, it must be removed and the Medical Records officer must place the document in the designated tray in the main medical records office, to be correctly filed in the correct Health Record.
 If the Rogue Document is found by Medical Records staff during their quality control of the electronic PR2 records, then the Rogue Document needs either to be redirected electronically into the correct patients record, the original hard copy of the document removed and correctly filed in the correct Health Record or rogue document to be printed and deleted from the wrong patient record and filed in the correct Health Record.

                               - 3 -

Step by Step Procedure

1. Selection of Documents to be scanned

The records to be partly scanned are stored in the Library.  Medical Records staff selects files (paper documents) for scanning
 Medical Records staff to remove the authorised documents.  Medical Records staff to complete the Patient Number on Number 1, date and initial on Number 2 of the Batch Header Form and place an elastic band around the batch.
 The Batch of documents that are stored for scanning must be logged in ledger and placed correctly on numbered shelf.

1. Splitting the files into PR1 & PR2

Note – PR1 these records represent the following:- All clinical records Correspondence Most recent 6 months of investigations All operation records All ECG’s Anything that scanners are unsure of, or is difficult to scan must seek advice or left in the PR1. PR2 documents represent the element of the medical record that, after scanning and quality control checks, will eventually be destroyed.

 Staffs that split each of the files must leave any PR1 documents in the record and removing any PR2 documents for the next stage of this process.  Key Principle –Staffs will complete a check for Rogue documents. If one is found, see the relevant procedure under Key Operational Principles. Note – there may be some documents with no name or hospital number on, if you come across one of these assume it is the correct file and deal with it as normal.

                               - 4 -

1. Preparation of Documents to be scanned

 Staffs will prepare the PR2 documents for scanning on a batch basis, removing all staples, paper clips, post it’s and any other fastening materials.  All documents must be neatly edged, if rugged please use the guillotine.  Key Principle –Staffs will complete a check for Rogue documents. If one is found, see the relevant procedure under Key Principles. Note – there may be some documents with no name or hospital number on, if you come across one of these assume it is the correct file and deal with it as normal.  One file will be one batch so that a patient’s record is not split over two different batches.

1. Preparing the Batch

 Medical Records staff will already have noted the Patient number, from the file, on the Batch Header Sheet.  Staffs to write consecutive numbers on each Batch Header Form in the Batch Header Form Number box, starting with 1 and slash, then the year eg.’1/04’. These will be recorded in a log later on.  Staffs to count the number of PR2 documents and separate in piles of approximately 40. The separate pile counts should be recorded on the back of the Batch Header Form, in the grid supplied. These piles will be rotate stacked where practical, so that they are kept together. If preparation is way ahead of scanning the piles may be stacked normally and banded together for smaller storage. Note – blank pages s

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