Guidance on the Use of Work Diaries and Associated Recording Workbooks

Guidance on the Use of Work Diaries and Associated Recording ‘Workbooks’

CONTENTS PAGE

Section Page

Number

1 Introduction 1

2 Associated Policies 1

3 Scope of Policy 1

4 Access of Ownership 1

5 Procedure 2

6 Breaches in Security and Lost Diaries 3

7 Audit, Monitoring and Review 3

8 References 3

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 1. INTRODUCTION

Leicestershire Partnership NHS Trust supplies work diaries to staff and departments for the purpose of keeping basic details of work to be undertaken on a daily basis during the calendar year.

The contents of these diaries are classed as official records, which may be required for legal and managerial investigations. Staff may use an alternative diary to that supplied by the employer with their managers’ permission, and on the condition that this becomes the employing authority’s property.

NHS staff have been using paper diaries over a number of years. In light of recent events around data loss and information security, the Department of Health has stipulated that more stringent measures around the use of paper diaries must be introduced (this includes staff diaries, workbooks and message books).

The Information Governance agenda has heightened and the organisation must respond to these new stricter and secure measures. The organisation has responded to this by introducing guidance relating to diaries. This guidance covers:

 Secure use of staff diaries  Issue and return of staff diaries  Agreeing local retention periods for ‘old’ staff diaries  Standardising the storage arrangements for ‘old’ staff diaries  Secure method of destruction

All of the above information security risks are extremely important but this guidance relates specifically to concerns with potential loss of:

 Personal Confidential Information (PCD)  Confidential Information (from patient, staff and business perspectives)  Sensitive Information (from patient, staff and business perspectives)  Evidence/Information required for legal proceedings (from patient, staff , business and criminal justice perspectives)

Although the information included in this policy is aimed at Clinical staff, it applies equally to all staff diaries.

2. ASSOCIATED POLICIES

This document draws from guidance issued by the Nursing and Midwifery Council (NMC 2009), the Health Professionals Council (2008) and the Records Management: NHS Code of Practice (DH 2006).

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 This policy should be considered in association with the following policies and guidance:

 Data Protection Policy  Management of the Quality of Health Records and Record Keeping Policy  Records Management Policy

3. SCOPE OF THE GUIDANCE

This guidance relates to all diaries, held by all staff, where they are the primary mechanism for managing workload and time. The diaries referred in this document relate to those staff who are required to use diaries in the planning and recording of work undertaken on a daily basis on behalf of the organisation.

This guidance must be followed by all staff who work for, or on behalf of LPT, including those on temporary or honorary contracts.

4. ACCESS OF OWNERSHIP

Leicestershire Partnership NHS Trust are the legal owner of the diary and the use of the diary may be audited at any point.

5. DEFINITIONS AND USES

5.1 Staff Paper Diary

The paper diary issued by LPT which is carried by an individual staff member is used to record time and activity of the individual on a daily basis.

Names or addresses of patients/clients or other activity locations should be listed in chronological order. Unless for a new patient or when providing cover, a combination of name and address must not normally be written together as it is not permitted to record Personal Confidential Information (PCD) in the diary (refer to the Secure Use of Paper Diaries below).

Mileage from base to all visits and back to base should also be recorded daily as an aide memoire including the name of any passenger or the name of the driver if not the diary of the keeper.

5.2 Computerised Print Outs

When a member of staff prints off a schedule for that days visits, for example from SystmOne, then the print out must be kept secure and confidential at all times. The print out must contain only the minimum amount of PCD to allow the member of staff to conduct the visit.

Following the visit and after recording on the relevant electronic patient record, all print outs must be disposed of securely as soon as possible when the member of Page 3 of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 staff returns to the office. This should be done either by shredding or placing in confidential waste containers.

5.3 Message Book

A book must be kept securely at base which is used to record messages to staff from both internal and external sources. The message may contain personal/sensitive information regarding a patient/client or indeed a member of staff e.g. address, telephone number, date of birth and how to access the house. This book should be kept locked away where an office is unmanned.

5.4 Work Book

A book used to record the allocation on a daily basis, of both time and activity for individual staff members. For the purposes of both audit and health and safety reasons it is always left securely at base (if a lone worker was unaccounted for a check could be made of where that person was last seen). This book should be kept locked away where an office is unmanned.

5.5 Electronic Diaries

Information recorded into staff calendars in Microsoft outlook, it is up to the individual staff to make sure that the information in their calendars does not identify patients unless absolutely necessary and is only accessible to colleagues with a need to know.

The purchase and operation of mobile devises must be done in accordance with the organisations Information Security Policy section on Remote and Mobile working.

5.6 Note Books

A book used to take notes during a clinical contact or at a clinically related meeting, as an aide memoire for transcribing into an electronic patient record or inserting into a paper-based record.

There should be one page used per patient/family which is then torn out and kept locked away securely until inserted into the case note or entered into the electronic record, and then shredded.

Note books containing PCD should not be taken from base unless in the course of undertaking duties but then returned at the end of the working day.

6. SECURE USE OF PAPER DIARIES (this includes staff diaries, workbooks and message books)

Paper diaries remain the property of LPT at all times. Staff are responsible for the safe keeping and secure storage of them.

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 All members of staff have a personal responsibility for ensuring any PCD, confidential or sensitive information is held securely at all times. Written information should be made secure and data should be made anonymous.

All staff must be reminded that they have a responsibility to ensure that no PCD is held in their paper diary, unless in response to point 5.1 above.

Refer to Appendix A relating to use of staff diaries

Recording Clinical information in the staff paper diary is discouraged. In the event that a patient is seen:

 Transfer information on return to the office  Put a line through and initial with a comment ‘updated patient record’.

7. ISSUE AND RETURN OF PAPER DIARIES

All staff are reminded that diaries are the property of the organisation and therefore, must refer to the organisations Data Protection Policy. Staff must pay particular attention to storage of these items.

7.1 Roles and Responsibilities

7.1.1 Staff

When a new paper diary is issued to a staff member they will be required to provide a signature to confirm that:

a. They have read the relevant policies b. They are aware of their responsibilities as required by these policies c. They agree to abide by Appendix A of this guidance

7.1.2 Team Leader/Manager

The Team Leader/Manager will be responsible for:

a. The ‘housekeeping’ of Appendix A of this guidance b. Ensure that all staff are aware of the relevant policies associated with Information Governance (IG) c. Giving staff a ‘Summary of IG Principles’ Leaflet when the diary is issued (Appendix A).

7.1.3 Staff Leaving the organisation

All staff leaving the organisation must return their paper diary to their Team Leader/Manager who will retain the diary until the end of the calendar year when it will be archived.

8. LOCAL RETENTION PERIODS

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 Under the terms of this guidance paper diaries, work books and message books will be retained for two years as follows:

 Keep completed diary for one year securely at the office base  Send to storage for the remaining one year period

9. STANDARDISING STORAGE ARRANGEMENTS FOR DIARIES

Information recorded into staff calendars in Microsoft outlook are stored and backed up on the Trust’s network servers.

For mobile devices, information can be downloaded straight onto the network where it can be stored for statutory timescales.

Please refer to the appropriate contact detailed in the relevant policy to arrange storage and all destruction arrangements in accordance with the current Records Management Policy

10. BREACHES IN SECURITY AND LOST DIARIES

Diaries must not be left on display in cars. Any incident relating to the loss of a diary must be reported using the LPT Incident Reporting form. The line manager must also be informed. The line manager will be required to take any necessary action.

NB If this policy is being adhered to, any diary losses will not fall into the category of an Information Governance Serious Incident.

11. DISSEMINATION AND ARCHIVING

This guidance will be published as part of the Management of the Quality of Health Records and Record Keeping Policy on the LPT Internet and staff Intranet on the Information Governance pages. It is the responsibility of line managers to ensure that members of staff are made aware of this guidance. New members of staff are advised during their induction process to look at the Internet and staff Intranet to ensure that they read and have a good working knowledge of all relevant policies, strategies, procedures and guidelines.

Previous versions of this guidance will be archived in accordance with organisational policy.

All staff are strongly discouraged form printing off or photocopying this guidance and should understand that the internet version of this guidance is the definitive version.

12. AUDIT, MONITORING AND REVIEW

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 An annual audit of diaries will be undertaken to coincide with the annual clinical record keeping audit.

The implementation of this guidance will be monitored by the Clinical Effectiveness Group, in line with the Quality Standards for Policy Development Policy requirements.

The Records and Information Governance Group will lead the review of the policy at least every 2 years, giving consideration to:

 Audit results from the audit of diaries  Change in legislation and guidance  Recommendations from external agencies

13. REFERENCES

Department of Health (2006) Records Management: NHS Code of Practice London. DH

Health Professionals Council (2008) Standards of conduct, performance and ethics London. HPC

Nursing and Midwifery Council (2009) Record Keeping: Guidance for nurses and midwives London NMC

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 APPENDIX A

INFORMATION GOVERNANCE PRINCIPLES FOR USE OF STAFF DIARIES

Please keep a copy in your paper diary (this includes staff diaries, work books and message books)

You are supplied with a diary to use in connection with your professional duties and the following points are drawn to your attention:

This diary remains the property of the Trust and must be retained by you for the statutory period or until returned for Archiving

In order to identify the staff member to whom the diary belongs, the name, base and landline telephone number should be recorded in the front of the diary.

 The diary must be used to record all visits/activities

- Name of the person seen (initial and surname)

- Location of the person on the first assessment i.e. home/clinic etc (to protect confidentiality), identified by road name only

- The visits/appointments must be recorded in the diary and an indication of the order in which they were visited/seen including any return visits to either base or patients’ homes

- If access to a visit is not gained, “No Access” must be recorded, unless you have the patient records, in which case it will be recorded directly into the record.

- If an appointment has been cancelled, the diary must reflect that the visit was cancelled and by whom, i.e. staff, patient, relative (unless recorded directly into the patient’s record). Page 8 of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012  Entries into diaries must be legible and written in black ink  Loss of the diary must be reported immediately to your line manager or on-call manager  The diary may be used to record details of mileage travelled, as an aide memoire, in accordance with the Travel and Mileage Policy  The diary must be available for audit at all times  Any patient related information must be dealt with as detailed in the policy.

DO NOT

 Keep diaries in the car overnight!  No loose pieces of paper should be carried in the diary i.e. prescription pads, payslips, referral sheets etc.  Use of liquid eraser such as Tippex is not acceptable for any reason. Correct error by a single line through the original entry and re-enter the information  Keep this diary longer than the agreed timescale within the policy

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 APPENDIX B

TEMPLATE FOR ALL PAPER DIARY ISSUE AND RETURN (including staff diaries, workbooks and message books)

Please keep this original copy together with the policy in your office base and keep it readily available for audit when required.

This form should be printed on an annual basis and upon receipt of staff returning previous year’s diary it can then be placed in the archive box for storage.

Department ………………………………………………………………………………...

Year: …………………….

Name of Person Date Paper Received Signature of Recipient Date Diary Receiving Diary Diary Copy of Returned issued Appendix A

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 TEMPLATE FOR ALL PAPER DIARY ISSUE AND RETURN (including staff diaries, workbooks and message books)

Please keep this original copy together with the policy in your office base and keep it readily available for audit when required.

This form should be printed on an annual basis and upon receipt of staff returning previous year’s diary it can then be placed in the archive box for storage.

Department ………………………………………………………………………………...

Year: …………………….

Name of Person Date Paper Received Signature of Recipient Date Diary Receiving Diary Diary Copy of Returned issued Appendix A

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 APPENDIX C

Related Training/ Policies

Name: Dept & Job title/ Designation Ward/Unit/Team:

Have you knowledge of/ signed as read and abiding by Initial self Final assessment date Assessment date:

Have undertaken Record Keeping training updates Yes/ No Yes/ No

LPT Policies

Clinical Record and Note Keeping Yes/No Yes/No

Consent Yes/No Yes/No

Records Management Yes/No Yes/No Yes/No Yes/No Information Governance Yes/No Yes/No Access to Patient Health Records Yes/No Yes/No Confidentiality and Data Protection Yes/No Yes/No Information Security Policy

Reference Guides

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012 Own professional Guidance/ Policy for record keeping Yes/No Yes/No  Records Management: NHS Code of Practice Part 1 and 2 Yes/ No Yes/ No  NHS Code of Confidentiality Yes/ No Yes/ No

of 13 Record Keeping and Management of the Quality of Health Records Policy v2.0 Final March 2012