Health Records Team

Records – Past, Present & Future

Records – Past, Present and Future

The Health Records Department at The State Hospital is unlike most other Health Records Department.  We are a small team, currently 3 members of staff, who come under the general eHealth umbrella.  Karen, the Health Records Manager has been here almost 20 years, Alan and Louise (Health Records Assistants) for 11 and 3 years respectively. 

Our remit over the years has included a variety of tasks, not only dealing with patient records but also providing statistics, managing visits from external bodies such as the Scottish Government and Mental Welfare Commission, and completing a variety of census information including the full population census.  We are also the place to go to for things which are a bit out of the ordinary – from phone calls from members of the public wanting to know what do with a dog belonging to a patient to staff who are not quite sure but “I’ve heard you may be able to help us …”.

Past

Twenty years ago the department was mainly used to support medical secretarial services, looking after patient records and carrying out admin tasks such as admissions.   The patient records were all on paper and filing meant dragging casenotes out of ‘dookits’ or going onto a ward with a huge pile of paper to go into the correct patient files.  Staff were managed by the Health Records Manager and worked closely with consultant psychiatrists and junior medical staff.  Over the years the remit of the department changed, beginning with centralising patient records from all the various areas of the hospital who had set up their own systems and beginning to work more with other clinicians.  One of the main jobs of the staff was to provide records to other agencies, and as the years progressed, provide copies of notes to patients or solicitors – meaning having to read the notes and remove third party information – a huge task in amongst everything else relating to health records duties.  With some staff changes over the years (with many going on to a career in nursing), the department has continued to develop and grow and is now almost unrecognisable to what it was then.  We had no real outlet for feedback – iMatter wasn’t around for most of this time.  Any issues were discussed at team meetings, or more often, behind the closed office door!

 Present

Currently we are in a strange situation – we are still a Health Records Department but are moving towards restructure and being a Records Services Department, providing help and support for all records in the Hospital.  Health Records will still be a priority, however staff are learning and developing their skills in records management.  It is becoming obvious that more co-operative working is required – we are beginning to work much more closely with other staff around the Hospital to promote and support good records management processes.  We are also involved in Information Governance processes, and in providing support in the admin of the Electronic Patient Record.  We no longer create paper patient records – almost everything is now electronic and filing means scanning and saving.  However, much of our time is still spent reading and redacting casenotes for Subject Access Requests, and supplying information to other agencies.  Staff have undertaken lots of training, particularly in Records Management and this is being used in various ways.  One of the most interesting projects currently is the appraisal of patient records – some going back to the early 1900s – for permanent preservation or destruction.  Some days it doesn’t even feel like coming to work! 

Over the past couple of years iMatter has been an important tool in developing the department.  We did try this as part of the wider eHealth Department, but it just didn’t quite work out and we’ve gone back to the department having its own report.  This works due to the honest and open working relationships in the department – when there are only 3 of you it’s hard to hide issues and problems.  iMatter has allowed us to discuss the wider issues affecting staff, and has been important in allowing us to move forward and work more proactively with staff around the hospital, trying to improve relationships and processes, which ultimately provide better experiences for patients and staff.

Future

Who knows what the future holds?!  If only we did it would be a fully functioning and resourced Records Services Department, allowing us to have a complete Information Asset Register and naming conventions that everyone used.  However, looking back at the changes which have taken place in the last few years, one thing is certain – it will not be boring!  With enthusiasm from the staff, and lots of encouragement for others, Records Management will hopefully become embedded in the culture of The State Hospital for many years to come.    

Our action plan for this year focusses mainly on the changing of the function of our department, going from Health Records to Records Services.  This includes:

• Concentrating on making sure our job descriptions are updated to reflect what we do and to keep us focussed
• Working closely with other areas to make records management a priority in the wider hospital.

What we are celebrating as a team:

• Being a small team who are able to work well together
• Being part of a larger team throughout the hospital
• Any other occasion requiring cake …