Information and Records Glossary

Access The availability of, or permission to consult, records. 
Appraisal The process of evaluating our activities to determine which records should be kept, and for how long, to meet the needs of the DHSC, the requirements of Government accountability and the expectations of researchers and other users of the records. The process of distinguishing records of continuing value from those of no value so that the latter may be eliminated. 
Archives Those records that are appraised as having permanent value for evidence of ongoing rights or obligations, for historical or statistical research or as part of the corporate memory of the DHSC. 
Authenticity An authentic record is one that can be proven:
·         to be what it purports to be;
·         to have been created or sent by the person purported to have created or sent it;
·         to have been created or sent at the time purported.
To ensure the authenticity of records, the DHSC should implement and document policies and procedures which control the creation, receipt, transmission, maintenance and disposition of records to ensure that record creators are authorised and identifiable and that records are protected against unauthorized addition, deletion, alteration, use and concealment. (BS ISO 15489-1:2001(E))
Caldicott Guardians A Caldicott Guardian is a senior person responsible for protecting the confidentiality of people’s health and care information and making sure it is used properly. The Department has two Caldicott Guardians: The Department has two Caldicott Guardians:
·         Dr Jugnu Mahajan is responsible for health care matters, contact details as follows:
Catherine Quilliam

Telephone:+44 1624 642643

Email:Send Email

·         Mike Williamson responsible for social care matters, contact details as follows: 
Mike Williamson

Telephone:+44 1624 656061

Email:Send Email

Caldicott Principles The Caldicott principles outline seven areas that all health and social care staff are expected to adhere to in addition to the DPA. These principles are: 
1.     Justify the purpose(s) 
2.     Don’t use personal confidential data unless it is absolutely necessary 
3.     Use the minimum necessary personal confidential data 
4.     Access to personal confidential data should be on a strict need-to-know basis 
5.     Everyone with access to personal confidential data should be aware of their responsibilities 
6.     Comply with the law 
7.     The duty to share information can be as important as the duty to protect patient confidentiality.
Classification The systematic identification and arrangement of business activities and/or records into categories according to logically structured conventions, methods and procedural rules represented in a classification system. (BS ISO 15489-1:2001(E)) 
Conversion  The process of changing records from one medium to another, or from one format to another. (BS ISO 15489-1:2001(E)) (see also Migration)
Corporate Records Records (other than health and social care records) that are of, or relating to, the DHSC’s business activities covering all the functions, processes, activities and transactions of the DHSC and of its employees.
Current Records Records necessary for conducting the current and ongoing business of the DHSC.
Destruction The process of eliminating or deleting records beyond any possible reconstruction. (BS ISO 15489-1.2001(E))
Disposal Disposal is the implementation of appraisal and review decisions. These comprise the destruction of records and the transfer of custody of records (including the transfer of selected records to an archive institution). They may also include the movement of records from one system to another (for example, paper to electronic). 
Disposition A range of processes associated with implementing records retention, destruction or transfer decisions which are documented in disposition authorities or other instruments. (BS ISO 15489-1:2001(E))
Electronic Record Management System A system that manages electronic records throughout their lifecycle, from creation and capture through to their disposal or permanent retention, and which retains their integrity and authenticity while ensuring that they remain accessible.
File An organised unit of documents grouped together either for current use by the creator or in the process of archival arrangement, because they relate to the same subject, activity or transaction. A file is usually the basic unit within a records series.
Filing System A plan for organising records so that they can be found when needed. 
Health and Social Record A single record with a unique identifier containing information relating to the physical, mental health or social care needs of a given patient or service user who can be identified from that information and which has been recorded by, or on behalf of, a health and social care professional, in connection with the support and care of that patient or service user. This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis or support pathway, justify the treatment or intervention and facilitate the ongoing care of the patient or service user to whom it refers.
Indexing The process of establishing access points to facilitate retrieval of records and/or information. (BS ISO 15489-1:2001(E)) 
Information Audit An information audit looks at the means by which an information survey will be carried out and what the survey is intended to capture.
Information Commissioner The Information Commissioner enforces and oversees the Data Protection Act 2002 and the Freedom of Information Act 2015.
Information Survey/ Records Audit A comprehensive gathering of information about records created or processed by the DHSC. It helps us to promote control over our records, and provides valuable data for developing records appraisal and disposal procedures. It will also help to:
·         identify where and when health, social care and other records are generated and stored within the Department and how they are ultimately archived and/or disposed of; and
·         accurately chart the current situation in respect of records storage and retention Department-wide, to make recommendations on the way forward and the resource implications to meet existing and future demands of the records management function.
Integrity of Records The integrity of a record refers to its being complete and unaltered. It is necessary that a record be protected against unauthorised alteration. Records management policies and procedures should specify what additions or annotations may be made to a record after it is created, under what circumstances additions or annotations may be authorised and who is authorised to make them. Any unauthorised annotation, addition or deletion to a record should be explicitly identifiable and
Jointly Held Records A record held jointly by health and social care professionals, for example within the Mental Health Directorate. A jointly held record should be retained for the longest period for that type of record, i.e. if social care has a longer retention period than health, the record should be held for the longer period.
Metadata Contextual information about a record. Defined in ISO 15489 as “data describing context, content and structure of records and their management through time”, metadata is structured information that enables the description, location, control and management of other information. Metadata should include (amongst other details) elements such as the title, subject and description of a record, the creator and any contributors, and the date and format. For further information please visit National Archives.
Microform Records in the form of microfilm or microfiche, including aperture cards.
Migration (also see Conversion) The act of moving records from one system to another, while maintaining the records’ authenticity, integrity, reliability and usability. (BS ISO 15489-1:2001(E)) 
Minutes (Master) Master copies are the copies held by the secretariat of the meeting, ie the person or department who actually takes, writes and issues the minutes.
Minutes (Reference) Copies of minutes held by individual attendees at a given meeting.
NHS Care Records Service Introduced in 1996, the NHS number is a unique 10 character number assigned to every individual registered with the NHS in England (and Wales). The first nine characters are the identifier and the tenth is a check digit used to confirm the number’s validity. Babies born in England and Wales are allocated an NHS number by Maternity Units, at the point of Statutory Birth Notification. The NHS number is used as the common identifier for patients across different. NHS organisations and is a key component in the implementation of the NHS CRS. Isle of Man patients who have received care in England or Wales will have an NHS number.
NHS Number All NHS records are public records under the terms of the UK Public Records Act 1958 sections 3(1)–(2). All records created and used by NHS employees are public records.
NHS Records Records in the form of files, volumes, folders, bundles, maps, plans, charts, etc.
Noble’s Hospital Number  
Paper Records Records in the form of files, volumes, folders, bundles, maps, plans, charts, etc.
Permanent Retention Records may not ordinarily be retained for more than 30 years. However, the Public Records Act provides for records which are still in current use to be legally retained. Additionally, under separate legislation, records may need to be retained for longer than 30 years, for example Occupational Health Records relating to the COSSH (Control of Substances Hazardous to Health) Regulations, or records required for variant CJD surveillance. Section 29 of the Data Protection Act permits personal data identified as being of historical or statistical research value to be kept indefinitely as archives.
Place of Deposit For example the Public Records Office.
Preservation Processes and operations involved in ensuring the technical and intellectual survival of authentic records through time. (BS ISO 15489-1:2001(E))
Protective Marking The process of determining security and privacy restrictions on records.
Public Records  
Public Records Act 1999 An act to establish a Public Record Office; to make provision for public records; and for connected purposes. The Act itself can be found by visitng Legalisation Webpage.
Publication Scheme  
Record Series A series is the main grouping of records with a common function or subject – formerly known as ‘class’. Documents arranged in accordance with a filing system or maintained as a unit because they result from the same accumulation or filing process, or the same activity, because they have a particular form, or because of some other relationship arising out of their creation, receipt or use. A series comprises the record of all the activities that are instances of a single process. A series may be large or small: it is distinguished not by its size, but by the fact that it provides evidence of a particular process. If an activity takes place that is unique, rather than an instance of a process, its records form a series in their own right. (Elizabeth Shepherd and Geoffrey Yeo, Managing Records: a handbook of principles and practice (Facet 2003))
Records Information created, received and maintained as evidence and information by an organisation or person, in pursuance of legal obligations, or in the transaction of business. (BS ISO 15489.1)
Records Management Field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records, including processes for capturing and maintaining evidence of and information about business activities and transactions in the form of records. (BS ISO 15489-1:2001(E))
Records System / Records Keeping System An information system which captures, manages and provides access to records through time. Records created by the organisation should be arranged in a record-keeping system that will enable the organisation to obtain the maximum benefit from the quick and easy retrieval of information. Record-keeping systems should contain descriptive and technical documentation to enable the system and the records to be understood and to be operated efficiently, and to provide an administrative context for effective management of the records, including a documented set of rules for referencing, titling, indexing and, if appropriate, the protective marking of records. These should be easily understood to enable the efficient retrieval of information and to maintain security and confidentiality.
Redaction The process of removing, withholding or hiding parts of a record due to either the application of a Freedom of Information Act exemption or a decision by The National Archives to restrict access where sensitivity, copyright or data protection issues arise. 
Registration Registration is the act of giving a record a unique identifier on its entry into a record-keeping system.
Retention The continued storage and maintenance of records for as long as they are required by the creating or holding organisation until their eventual disposal, according to their administrative, legal, financial and historical evaluation.
Review The examination of records to determine whether they should be destroyed, retained for a further period, transferred to an archival establishment, or presented to a third party (for example a University).
Tracking Creating, capturing and maintaining information about the movement and use of records. (BS ISO 15489-1:2001(E))
Transfer of Records Transfer (custody) – Change of custody, ownership and/or responsibility for records. (BS ISO 15489-1:2001(E))
Transfer (movement) – Moving records from one location to another. (BS ISO 15489-1:2001(E)). Records identified as more appropriately held as archives should be offered to Public Records Office, which will work with the DHSC Head of Information and Records Management to make a decision regarding their long-term preservation.
Weeding The process of removing inactive/non-current health records from the active/ current or primary records storage area to a designated secondary storage area after a locally agreed timescale after the date of last entry in the record.

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