Records Management Processes
Implementing and maintaining effective records management depends on the knowledge of what records are held, where they are stored, who manages them, in what format(s) they are made accessible, and their relationship to organisational functions (for example finance, estates, IT, healthcare or social care provision). An information survey or record audit is essential to meeting this requirement. This survey will also help to enhance control over the records, and provide valuable data for developing review and disposal policies and procedures.
There should also be audits of the content of clinical records. The Royal College of Physicians health informatics unit developed an audit tool to support the implementation of the generic medical record-keeping standards and it is available at http://www.rcplondon.ac.uk/resources/clinical-resources/standards-medical-record-keeping/audit-tool-generic-standards