Administrative Records Management Policy
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lefttopDGD17-014Policy Administrative Records Management Policy StatementGood recordkeeping is critical to ACT’s Health corporate governance and operational efficiency, provides essential evidence of business activities and transactions, and demonstrates accountability and transparency in ACT Health’s decision-making processes.This Policy and ACT Health’s Administrative Recordkeeping Procedures Manual (“the Manual”) have been developed to assist ACT Health to comply with the Administrative Records Management Program, the Territory Records Act 2002 (“the Act”) and the Territory Records Office (TRO) Standard and Guidelines. Where specific recordkeeping guidance is not contained within this Policy or the Manual, ACT Health staff must ensure that they comply with the TRO requirements, in addition to the Australian Standard on Records Management, AS ISO 15489.All staff within ACT Health are responsible for recordkeeping. All staff must therefore be aware of their obligations under this policy and take reasonable action to ensure ongoing compliance. All ACT Health paper records will be titled according to the Whole of Government Thesaurus as provided by the TRO. Digital records held in business systems must be actively managed including effective metadata management. DigitisationFor procedures about the process of, and requirements for, digitising Territory records, refer to the Manual and the TRO Fact sheets available on the TRO webpage: This policy should be read in conjunction with the Manual and should be referred to in applicable organisational policies and procedures to ensure a consistent approach to recordkeeping throughout ACT Health.PurposeThe purpose of this Policy is to provide direction to staff in relation to the creation, maintenance, storage and disposal of administrative records within ACT Health. The accompanying Manual supporting this policy is intended to ensure best practice records management within ACT Health, particularly during the transition from a primarily paper-based system to an Electronic Document Records Management System (EDRMS) environment.The making and keeping of complete and accurate records of ACT Health’s activities is essential to attain its stated outcomes. It is essential therefore for all staff to make and keep complete and accurate records of their activities, ensure that such records are incorporated into ACT Health’s recordkeeping system, and comply with all records management procedures. Full and accurate records also provide evidence of ACT Health activities for accountability and legal purposes and meet expectations of the community. ScopeThis policy applies to all administrative records from the time of creation or capture and covers:all aspects of ACT Health’s business operationsall types and formats of records created to support business activitiesorganisations and businesses, including their employees, to which ACT Health has outsourced its functions or activities, including associated recordkeeping responsibilities.OwnershipAll records generated by full-time, part-time staff, casual staff, volunteers, consultants and /or contractors as part of their duties are Territory records and belong to ACT Government and not to individual employees in ACT Health.ExclusionExcluded from this policy are ACT Health clinical records which are addressed under the ‘Clinical Records Management’ policy, in conjunction with associated procedures and supported by the Clinical Records Management Manual.Roles & ResponsibilitiesEvery employeeAll staff must adhere to ACT Health’s Administrative Records Management policy, manual and standards in maintaining records as required within their duties and to the Act.Staff are responsible for the creation and management of records in regards to the work they perform on behalf of the organisation. Additional responsibilities for certain staff are outlined below. All staff in the possession of official registered administrative records are responsible for ensuring that the records are re-assigned to another staff member or else returned to Records Management storage on the reallocation of workload. In the event of transferring to another business unit, or if ceasing employment with ACT Health - refer to the Manual for further information. Staff must not destroy records without the authorisation from ACT Health’s Records Management Unit, except for unregistered material and through the appropriate application of Normal Administrative Practices (NAP) – refer to the Manual for further explanation. Only records that have been appraised and identified in conjunction with disposal schedules approved by the Director of Territory Records as allowable for destruction will be destroyed.Links with Aboriginal and Torres Strait Islander HeritageRecords created, received or discovered which contain information that may allow people to establish links with their Aboriginal or Torres Strait Islander heritage will be appropriately managed, protected and made accessible if needed. Director-General The Director-General is ultimately responsible for the management of records, has authorised this policy, promotes compliance with this policy, supports and fosters a culture of good recordkeeping in the organisation, and ensures the Records Management Program is adequately resourced.Records Manager and/or ACT Health Records Management The Records Manager and/or ACT Health Records Management are responsible for implementing and monitoring recordkeeping legislative and best practice requirements across ACT Health. An important aspect includes the identification of records management requirements, and the development, implementation and periodic review of the policy and manual to ensure its currency with best practice/standards. Authorised Recordkeeping SystemACT Health’s authorised and compliant EDRMS is Hewlett-Packard Records Manager (HP RM). Records Management will ensure that the recordkeeping system is measured and monitored to ensure that the identification and retrieval of information remains consistent and meets the needs of the Records Management Program and business rmation and Communication Technology (ICT) Professional staffICT staff, including Shared Services ICT staff, are responsible for maintaining the technology for business systems, including appropriate system accessibility, security and back-ups in accordance with ICT policies. Security AdvisorThe Security Advisor provides advice on security policy and guidelines associated with the management of records.Managers and SupervisorsManagers are ultimately responsible for ensuring that all records produced by their area are captured, maintained and accessibly stored in accordance with this policy.Managers and supervisors are therefore responsible for ensuring that staff, consultants and / or contractors under their responsibility are made aware of their records management obligations and what information resources and training is available to them.?They should also advise the Records Manager and/or Records Management Unit of any changes in the business environment, such as restructures. Refer to the Manual for further information.Volunteers, contractors, consultants and service providersVolunteers, contract staff, consultants and service providers must create and manage records in accordance with this policy and supporting Manual.EvaluationOutcome MeasuresACT Health compliance with the requirements of the Territory Records Act 2002 and the TRO Standard and Guidelines for Records Information and Data.Records Management has established key performance indicators which are reported to the Executive Director, Business Support Services on a regular basis, and available on request.MethodRecords Management practices will be subject to audits, conducted by the ACT Health internal auditors, the TRO or the ACT Government Auditor-General or others, as endorsed by the Director-General of ACT Health.Findings from audits are provided to the Director-General and other relevant Executive Directors and Managers. Records Management provides an Annual Report to the TRO and the annual Board Assurance on Compliance e-System (BACeS) compliance report.Related Policies, Procedures, Guidelines and LegislationPolicies and Procedures A range of policies relevant to the management of records must be applied alongside this policy, including:Clinical Records Management Policy, DGC12-048 Data Quality Framework, DGC14-006 ACT Government’s Open Government PolicyACTPS Digital Records PolicyACT Government Policy on the Selection and Implementation of Electronic Document and Record Management System (EDRMS) CapabilitiesACT Government’s Code of ConductACT Government’s Code of EthicsStandardsAS ISO 15489 - Standard on Records ManagementSA/SNZ TR ISO 26122 – Work Process Analysis for RecordkeepingAS: 5044 - AGLS Metadata Standard.AS/NZS 5478:2015 Recordkeeping Metadata Property Reference Set.ISO: 16175 - Principles and Functional Requirements for Records in Electronic Office EnvironmentsThe Territory Records Office Standard and Guidelines for Records, Information and DataAustralian Commission?on Safety and Quality in Health Care (ACSQHC)?National Safety and Quality Health Service (NSQHS) Standard 1 – GovernanceLegislationTerritory Records Act 2002Dangerous Substances ACT 2004 Freedom of Information Act 1989Evidence Act 2011Information Privacy Act 2014Health Records (Privacy and Access) 1997 Electronic Transactions Act 2001Financial Management Act 1996Medicines, Poisons and Therapeutic Goods Act 2008 Public Sector Management Act 1994Radiation Protection Act 2006 Work Health and Safety Act 2011Working with Vulnerable People (Background Checking) Act 2011Definition of Terms Clinical Record - Also referred to as a “Health Record”. Digital record - A record that is communicated and maintained in a digital format. Same as an electronic record.Disposal - identify records with similar disposal dates and triggering actions, review any history of use to confirm or amend the disposal status, and maintain a record of disposal action that can be audited. Health Record - means any record, or any part of a record:held by a health service provider and containing personal information; orcontaining personal health information.HP Records Manager (HP RM) is an electronic document and records management system (EDRMS). Formerly known as HP TRIM, HP RM is an enterprise document and records management system for physical and electronic information designed to help businesses capture, manage, and secure business information in order to meet governance and regulatory compliance obligations.Metadata - Structured descriptive data that must be captured in a recordkeeping system to enable a record to be understood, verified, managed and used. It is data describing context, content and structure of records and their management over time.Normal Administrative Practice (NAP) - allows for the destruction of non-essential information. To assist with the preservation of essential and vital information disposal schedules are created. Refer to the Manual for further information.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 (AS ISO 15489).Records Management - The 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 (AS ISO 15489).Records Management Program - A document that complies with section 16 of the Territory Records Act 2002 by setting out the means by which an agency will manage its records, and is approved by the agency’s Principal Officer (Director-General).Thesaurus - A uniform and standardised classification of terms based on the business functions and activities of an agency that provides controlled vocabulary and consistency for classifying, titling and indexing. A hard copy thesaurus in an electronic records management system provides system prompts that assist with titling and indexing files. Search Terms Administrative RecordsHP RM Records Records ManagementThesaurusTRIMDate AmendedSection AmendedApproved ByPAC ................
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