Fact Sheet 1 - General Information on Recordkeeping

Fact sheet 1: General information on recordkeeping

Records management for organisations funded under the Service Agreement
Fact sheet 1: General information on recordkeeping

Fact sheet 1: General information on recordkeeping1

Date: April 2016

This fact sheet is produced by the Victorian Department of Health and Human Services in support of the Service Agreement and its requirements in regard to recordkeeping. Information in this fact sheet is for general guidance only and references to contractual or legislative obligations are descriptive only. The Service Agreement and any applicable laws or legislation, including all standards and materials issued by the Public Record Office Victoria (PROV), take precedence over this fact sheet. The fact sheet does not constitute and must not be relied upon as legal or other professional advice. Each funded organisation should always obtain specific legal or other professional and recordkeeping advice tailored to its individual circumstances as needed. No liability is accepted by the department for any loss, damage, cost or expense incurred as a result of reliance on this document.

Records

Under the Service Agreement, a record is any document within the meaning of the Evidence Act 2008 (Vic.), including:

•anything on which there is writing; or

•anything on which there are marks, figures, symbols or perforations having a meaning for persons qualified to interpret them; or

•anything from which sounds, images or writings can be reproduced with or without the aid of anything else; or

•a map, plan, drawing or photograph,

created, managed, maintained, brought into existence or otherwise acquired or used by an organisation in relation to funding provided by the department under the Service Agreement, the services provided by the organisation under the Service Agreement, and performance of the organisation’s obligations under the Service Agreement.

Recordkeeping

A well maintained records management system supports the delivery of quality client-centred services.

Recordkeeping processes underpin our day to day actions and all organisations should have an ongoing commitment to continuous improvement in this area.

The priority for recordkeeping is that client related records are created about the services clients receive and decisions that are made that affect their lives. These records need to be kept securely, in a format that is safe from deterioration see Fact sheet 2: Storage. Clause 6 of the Service Agreement requires organisations funded by the department to retain records of clients in an accessible format for as long as the prescribed retention period (see Fact sheet 4: Record disposal and transfer and Record retention guide for funded organisations).

It is essential that all records that relate to the provision of the services to clients are kept in accordance with PROV requirements. For example, staff and volunteer records may need to be accessed in the event that a complaint is made by a client, as well as board meeting minutes if they reflect a decision made about a client.

Why keep records?

Client care

Documentation and recordkeeping are important as records provide a case history and a holistic picture that may be needed to follow up on services or try different approaches to assist clients. This is especially true for clients with long term or complex needs, or who need multiple services.

Accountability

It is important to be able to access relevant client information at any given time and find evidence of the organisation’s response to a client’s needs. Subject to applicable privacy laws, the information may be needed to respond to queries from stakeholders who may include the client’s family, donors, health professionals, the coroner, courts or the client themselves. The client record is an important source of information as it outlines the nature of the professional relationship with the client. Information on problems encountered and the organisation’s response may assist in the event of a crisis or investigation.

Service improvement

Well documented records can also assist with improving services to clients by helping staff to learn from and improve upon past decisions and actions. Records are an important source of information for service reviews.

For these reasons, funded organisations are required through their Service Agreements to ensure they have good recordkeeping practices consistent with applicable standards established under the Public Records Act 1973 (Vic.) and be able to provide copies of records to the department if requested.

Organisations funded by the department

It is in the interest of former and current clients of funded organisations that their records be secure and accessible throughout the course of their lives.

Organisations may be required to maintain safe custody of records well beyond the duration of their relevant Service Agreement. See Fact sheet 4: Record disposal and transfer for information regarding retention standards issued by PROV.

Records created and managed under the Service Agreement should be kept according to applicable legislation, including the following:

•Public Records Act 1973 (Vic.) including applicable standards established by the Keeper of Public Records (Public Record Office Victoria)

•Evidence Act 2008 (Vic.)

•Evidence (Miscellaneous Provisions) Act1958 (Vic.)

•Crimes Act 1958 (Vic.)

•Privacy and Data Protection Act 2014 (Vic.)

•Freedom of Information Act 1982 (Vic.)

•Health Records Act 2001 (Vic.).

Features of Good Practice

•A client record system that is up-to-date and used consistently by staff.

•Policy and procedures for records management that cover:

–collecting information

–recording and updating information

–access to and use of records

–security of records

–storage, transport and archiving.

•The structure and content of client records are organised to make access to key information easy and prevent loss of important documents.

•Staff have access to client information held in files on a ‘need to know’ basis.

•Relevant staff understand how to collect information and maintain records.

•Staff view the record system as an important component of providing good service to clients.

•All records containing client information are securely stored when not in use and when the organisation is closed.

•Use of records by staff is monitored and file audits are undertaken to ensure files are complete, up-to-date, and procedures are being followed.