An audit trail is a sequence of steps documenting the movement and/or editing of a record resulting from activities by individuals, systems or other entities
NHS Borders will adopt naming conventions and version control. This guidance is part of the NHS Borders Local Records Managers Guidance. Training on this will also be included with the roll-out of the Business Classification Scheme. Organisation wide consultation of the records naming convention is in the first phase of the implementation of this RMP and will be undertaken during 2016.
Health Records are tracked electronically within NHS Borders' Patient Administration Systems.
The tracking of movement and changes to records is undertaken as appropriate based on assessment of risk, and commensurate with the sensitivity of information which they contain, and its value as evidence. Inappropriate access is identified through the 'FairWarning' system and disciplinary proceedings implemented, as documented in the Inappropriate Access to Health Records - Managers Guidance.
NHS Borders currently has no plans to introduce an Electronic Document Management System so a robust manual system is to be devised. This work is scheduled to commence late 2016 and is expected to be fully implemented by 2020.