RETENTION AND DESTRUCTION OF RECORDS POLICY Approved by:

Transcription

1 Title: Date Approved: March 2013 RETENTION AND DESTRUCTION OF RECORDS POLICY Approved by: Information Governance Group Division/Department: Information Governance Author (post-holder): Information Governance Manager Date of review: September 2015 Policy Category: Policy Ref: ISP_10 Corporate Information Sponsor (Director): Chief Executive CONTENT Issue: 5.4 SECTION DESCRIPTION PAGE 1 Introduction 3 2 Policy Statement 4 3 Definitions 4 4 Roles and Responsibilities 4 5 Scope of Policy 5 6 Consultation 6 7 Aims and Objectives of the Policy 6 8 Evidence Base 8 9 Monitoring Compliance 9 10 Training Requirements Distribution Communication Author and Review Details Appendices Health Records Finance PAS IM & T Supplies Administrative Human Resources Estates / Engineering Risk Management Research and Development Pharmacy Records Pathology Records Further Guidance 80 The issue of this page is the overall issue of this procedure.

2 The current issue of individual pages are as follows: PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 PAGE ISSUE DATE 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 02/13 Page 2

3 1 INTRODUCTION 1.1 The way in which information is recorded and maintained within an organisation is critical to effective business function. The way in which documents are controlled is essential to maintain working practices throughout the Trust. Without this consideration, records quickly become disorganised and useless. 1.2 Without adequate maintenance of our records, trust in our organisation to provide high standards of care will diminish, and in working practice, create greater repetition of tasks. 1.3 The purpose of the Retention and Destruction Policy is: to provide all staff with a clear and precise framework in which to work, to prevent unnecessary retention of documents, and unnecessary use of storage space to ensure that the Trust conforms to NHS Guidance and to ensure compliance with our legal responsibilities. 1.4 The destruction of records is an irreversible act. Decisions regarding the destruction of documents should be made using the criteria stated below, which gives guidance on the minimum retention periods. When the schedule is used, the guidelines listed below should be followed: Local business requirement/instructions must be considered before activating retention periods in this schedule. Decisions should also be considered in the light of the need to preserve records, whose use cannot be anticipated fully at the present time, but which may be of value to future generations. Recommended minimum retention periods should be calculated from the end of the calendar or accounting year following the last entry on the document. The selection of files for permanent preservation is partly informed by precedent and partly by historical content. The provision of the Data Protection Act must be complied with. Permanent Preservation of records means that they should be retained for no longer than 30 years after their creation. This includes all types of records, unless departmental decisions have been taken to preserve records for a longer period of time. 1.5 This Policy is issued and maintained by the Chief Executive (the sponsor) on behalf of the Trust, at the issue defined on the front sheet, which supersedes and replaces all previous versions. 3

4 2 POLICY STATEMENT 2.1 The Sherwood Forest Hospitals NHS Foundation Trust Board acknowledges the importance of records and is committed to create, keep, maintain and dispose of records, including electronic records, commensurate with legal, operational and information needs. 2.2 An Equality Impact Assessment (EIA) has been carried out and has concluded that this policy is of low impact. 3 DEFINITIONS 3.1 In this Policy, Records : means all records completed and held in respective of the Trust s business that contain information relating to both health and administration. Records include both paper based and electronic records. The PRA : means the Public Records Act The PRO means the Public Records Office. The Policy : means the. The Trust : means Sherwood Forest Hospitals NHS Foundation Trust. 4 ROLE AND RESPONSIBILITIES 4.1 Statutory Responsibility 4

5 The Secretary of State for Health and all NHS organisations have a duty under The PRA to make arrangements for the safekeeping and eventual disposal of all types of their records. This is carried out under the overall guidance and supervision of the Keeper of Public Records who is answerable to Parliament. All NHS records are public records under the terms of The PRA Schedules 3(1)-(2). Chief Executives and senior managers of all NHS organisations are personally accountable for the destruction of records within their organisation. 4.2 Managerial Responsibility The Board has responsibility, in compliance with the Trust s Governance Manual, to ensure and gain assurance that the Trust has in place robust arrangements for the destruction of records and that such arrangements are compliedwith The Chief Executive has responsibility to implement robust and appropriate record management arrangements in accordance with national and statutory requirements The Chief Executive delegates this responsibility to Executive Directors, Divisional Managers, senior managers and Record Managers within the Trust The Information Governance Manager will provide support and guidance for the implementation, and its subsequent on-going use. 4.3 Individual Responsibility All members of Trust staff are responsible for any record that they create or use. This responsibility is established at, and defined by, the law. Everyone working for the Trust and for the NHS generally who records, handles, stores or otherwise comes across information has a personal common law duty of confidence. 5 SCOPE OF POLICY This policy relates to the retention and destruction (or permanent preservation) of all records of the Trust, including but not limited to: Accounting records and budgetary information; Board, committee and sub-committee meeting minutes; 5

6 Contracts; Diaries; Health records (including NHS and the private healthcare sector); Invoices; The contents of Personnel files; Payroll / PAYE records; Litigation dossiers, including complaints, claims and inquest files; Policy and procedure manuals; Software licences; VAT records. 5.2 This policy does not address the creation and management of records. These matters are covered by separate complementary policies; Health Records Management Policy and Administrative Records Management Policy. 6 CONSULTATION 6.1 The Policy will be considered and approved by the: Medical Records Advisory Group Information Governance Group Risk Management Committee 7 AIMS AND OBJECTIVES OF THE POLICY 7.1 Objectives The main objectives of the Policy are to ensure: Accountability That adequate records are maintained to account fully and transparently for all actions and decisions, in particular: 6

7 To protect legal and other rights of staff or those affected by those actions; To facilitate audit or examination; To provide credible and authoritative evidence if required by law Quality That all records are periodically and routine reviewed to determine what can be disposed of or destroyed. This will guarantee the quality of the records that are selected for permanent preservation Accessibility Training Security That records which have been selected as archives should be held in a repository that has been approved by The National Archives. This will guarantee appropriate conditions for storage and access. That all staff are made aware of their responsibilities with regard to the retention and destruction of records on Induction through their Line Manager and as part the mandatory Information Governance training programmes and guidance. That the destruction of confidential records ensures that confidentiality is fully maintained. Destruction should be by cross cut shredding. Currently a contractor provides this service, but it is the responsibility of the Trust to satisfy itself that the methods used throughout all stages, including transport to the destruction site, provide satisfactory safeguards against accidental loss or disclosure. Papers and files containing confidential information must be disposed of in a secure manner and must not be disposed of with other domestic waste. Confidential waste must be held in a secure manner at all times prior to shredding, including in the Facilities Management (FM) building which is the central disposal holding area. Confidential waste such as un-shredded medical records, nursing records and personal files for example, must be placed into green confidential waste bags and arrangements made for them to be collected by portering staff via the FM Helpdesk (ext 3005). Ward confidential waste must 7

8 also be bagged in green bags and be placed in the waste disposal holds and a scheduled collection will be undertaken daily. Where departments shred their own confidential waste, arrangements must be made for them to be collected by portering staff via the FM Helpdesk (ext 3005). Where departments have a blue confidential waste container, waste should be deposited within and the container removed by the Service Providers Performance Measurement That the application of retention and destruction of records procedures are regularly monitored against agreed indicators and action taken to improve standards as necessary. 7.2 Notes on preservation of patient records for historical purposes In light of the latest trends in medical and historical research, it may be appropriate to select some of these records for permanent preservation. Selection should be performed in consultation with health professionals and archivists from an appropriate place of deposit. If records are to be sampled, specialist advice should be sought from the same health professionals and archivists. If an NHS Trust has taken on a leading role in the development of specialised treatments, then the patient records relating to these treatments may be especially worthy of permanent preservation If a whole run of patient records is not considered worthy of permanent preservation but nevertheless contains some material of research value, then the option of presenting these records to a local record office and other institutions under S.3(6) of The PRA should be considered. Advice on the presentation procedure may be obtained from The PRO s Archive Inspection Services If a whole run of patient records is considered worthy of permanent preservation but there is a lack of space in the relevant place of deposit to store these records, it may be appropriate to make a microfilm copy and then destroy the paper originals. Microfilms should be produced in accordance with the British and International Standard BS ISO 6199: 1991, copies of which can be purchased from the British Standards Institute. Any further advice required to implement this policy should be directed to: Information Governance Manager ext

9 7.2.4 All electronic and paper records that are selected for destruction must be recorded on the departments Destruction Log, an example of which can be found in Appendix 1. 8 EVIDENCE BASE 8.1 This Policy has been developed with reference to: Department of Health - Records Management: NHS Code of Practice Parts 1 and 2 NHS Litigation Authority Standards Healthcare Commission Standards 8.2 This policy is to be used in conjunction with the following complementary policies: Health Records Management Policy Administrative Records Management Policy Information Security Policy Information Governance Policy Information Sharing Protocol Internet and Policy Freedom of Information Policy Access to Health Records Guidance 9 MONITORING COMPLIANCE The following bodies monitor NHS performance in respect of records retention and destruction: The Board is responsible for monitoring compliance with the Policy through the Risk Management Committee and ensuring that there are clear lines of accountability Connecting for Health through the annual completion of the Information Governance Toolkit, reviews the status of records retention and destruction within the Trust. 9

10 9.1.4 The Care Quality Commission (CQC) regularly conducts studies into records management and related information quality issues All policy matters relating to the retention and destruction of records, are the responsibility of the Information Governance Group that reports to the Risk Management Committee, that is a sub-committee of the Trust s Board The Trust s Information Governance Manager monitors the retention and destruction of records policy and procedures. This will ensure that this policy and any relevant procedures operate in close association with the Data Protection Act 1998, Freedom of Information Act 2000 and other Information Governance aspects. The monitoring will include service performance and a review of all reported incidents of accidental loss or the disclosure of records. The Trust s Information Governance Manager will report to the Information Governance Group when an incident has been reported and an IG investigation has taken place. 10 TRAINING REQUIREMENTS 10.1 All staff must be appropriately trained by their Line Managers so that they are fully aware of their responsibilities in respect of the retention and destruction of records. Additional training will be provided through the IG mandatory annual update sessions and advice and guidance is available from the Information Governance department of ext Staff induction programmes will include training on the retention and destruction of records Directorate Records Managers are to ensure specific training is given to all staff Staff transferring between Divisions or Directorates will require additional induction training from their new Line Managers in order to familiarise themselves with new records and filing systems Nominated Records Managers will require training appropriate to their specific needs The Information Governance Manager will advise on training activities and provide guidance for any identified gaps in training. 10

11 11 DISTRIBUTION The Policy, once approved, will be included within the Governance Policy section of the Trust s Intranet. 12 COMMUNICATION All Directors and Divisional General Managers will be informed of the Policy and will be asked to ensure that their Records Managers are provided with access to the Policy for implementation. 13 AUTHOR AND REVIEW DETAILS Date issued: February 2013 Date to be reviewed by: To be reviewed by: February 2015 Information Governance Manager Executive Sponsor: Chief Executive 11

12 14 APPENDICES APPENDIX 1 Records Destruction Log Description of Record to be Destroyed account for Joe Bloggs Minutes of Health & Safety Committee Electronic or Paper format Owner/Department Person Authorising Destruction Electronic NHIS Service Desk Manager Paper Human Resources Assistant Director of HR Retention Period Date of Destruction 1 year years

13 15 HEALTH RECORDS Record Type/Sub Type Abortion Certificate A (form HSA1) and Certificate B (Emergency Abortion) Accident and Emergency records (where these are stored separately from the main patient record) Accident and Emergency Registers (where they exist in paper format) Admission Books (where they exist in paper format) Adoption records (administrative) see non health records Pre-Adoption Records Minimum Retention Notes Period (Years) 3 For the period of time appropriate to the patient/specialty, e.g. children s A&E records should be retained in line with records of children and young people. 8 after the year to which they relate. Likely to have archival value. See Note 1. 8 after the last entry. Likely to have archival value. See Note 1. Records, where the NHS number has been changed following adoption, will be returned to the appropriate PCT and they should be retained securely and confidentially for the same period of time as all records for children and young people. Genetic information should be transferred across to the post-adoption record. Retain until the patient s 25 th birthday or 26 th if 13

14 Ambulance records patient identifiable component (including paramedic records made on behalf of the Ambulance Service) Angiography tapes and disks Asylum seekers and refugees (NHS personal health record patient-held record) Audio tapes of calls requesting care (PCT, GP, NHS Direct Records etc) Audiology records young person was 17 at conclusion of treatment, or 8 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the advice of clinicians should be sought as to whether to retain the records for a longer period. 10 (applies to ALL Ambulance Clinical Records). NB. Where a patient is transferred to the care of another NHS organisation all relevant clinical information must be transferred to the patients health record held at that organisation. Derives from the Limitation Act. Destroy under confidential conditions. Please refer to the Trust s Waste Management Policy section 7.3 and section Special NHS record patient held no requirement on NHS to retain. 3 (providing all relevant clinical information has been transferred to the appropriate patient record. Where the information is NOT transferred into a health record, tapes should be retained for 10 years. For the period of time appropriate to the patient/specialty, e.g. children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient Derived from the Limitation Act Destroy under confidential conditions. Please refer to the Trust s Waste 14

15 Audit Trails (Electronic Health Records) Autopsy records see post mortem records and registers Birth Registers (i.e. register of births kept by the hospital) Birth Notification (to Child Health Dept) died while in the care of the organisation. NHS organisations are advised to retain all audit trails until further notice. Lists sent to General Register Office on a monthly basis. Retain for 2 years. Retain until the patient s 25 th birthday or 26 th if young person was 17 at conclusion of treatment, or 8 years after death. Likely to have archival value. See Note 1. Blood transfusion records (see pathology records) Body release forms 2 Breast screening x- rays (see Mammography Screening) Care records compiled by For the period of time appropriate to the patient/specialty, e.g. children s records should be employees of a Care retained as per the retention period for the records Trust (including of children and young people; mentally disordered information on an persons (within the meaning of the Mental Health individual s Act 1983) 20 years after the last entry in the educational status, record or 8 years after the patient s death if patient care needs, etc) died while in the care of the organisation. Cervical screening 10 15

16 slides Chaplaincy records 2 Likely to have archival value. See Note 1. Child and family guidance For the period of time appropriate to the patient/specialty, e.g. children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. Child Health Record Retain until the patient s 25 th birthday or 26 th if young person was 17 at conclusion of treatment, or 8 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the advice of clinicians should be sought as to whether to retain the records for a longer period. Child Health Records (notification of Visitors/New Entrants into a borough either from abroad, or from within the UK from Airports, the Home Office Immigration Centre and the Housing Options Teams) Database of notifications entries should be retained for 2 years. Where a health visitor visits the child the record of the visit should become part of the patient s record and retained until their 25 th birthday or 26 th birthday if an entry was made when the patient was 17 or 10 years after the patient s death if patient died whilst in the care of the organisation. This also applies to any other information that relates to patient care recorded by the health visitor for these purposes. Other information should be retained for a period of 2 years from the end of the year to which it relates. 16

17 Child Protection Register (records relating to) Children and young people (all types of records relating to children and young people) Retain until the patient s 26 th birthday or 8 years after the patient s death if patient died while in the care of the organisation. Retain until the patient s 25 th birthday or 26 th if young person was 17 at conclusion of treatment, or 8 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain the records for a longer period. Clinical audit records 5 Clinical Protocol (GP, in-house) 25 Clinical psychology 20 See Note 1. Clinical trials (see research records) Contraception and Sexual Health Records (Including where a scan is undertaken prior to termination of pregnancy but the patient goes elsewhere for the procedure) Controlled drug documentation (Moved from 8 (in adults) or until 25 th birthday in a child (age 26 if entry made when young person was 17), or 8 years after death. See also Guidance on the Retention & Disposal of Hospital Notes, British Association for Sexual Health and HIV (BASHH) guidance_retention_disposal_notes_0606.pdf Requisitions 2 years Registers and CDRBs 2 years from last entry Extemporaneous preparation worksheets 13 Derived from Clinical Standards Committee, Faculty of Sexual and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists. NB. The longest license period for a contraceptive device is 10 years. Derived from Misuse of Drugs Act Destroy under confidential conditions. Please refer to the Trust s Waste 17

18 Pharmacy Records) years Aseptic worksheets (adult) 13 years Aseptic worksheets (paediatric) 26 years External orders and delivery notes 2 years Prescriptions (inpatients) 2 years Prescriptions (outpatients) 2 years Clinical trials - 5 years minimum (may be longer for some trials) Destruction of CDs 7 years Future Regulations may increase the period of time for the storage of records. Please refer to the DOH and Royal Pharmaceutical Society of Great Britain websites for up to date information. Misuse of Drugs Regulations Safer management of controlled drugs: a guide to good practice in secondary care (England). October 2007 DOH, 17 th October Publications/PublicationsPolicyAndGuidance/DH_ Counselling records Creutzfeldt-Jakob Disease (hospital and GP) Death cause of, certificate counterfoils Death registers i.e. register of deaths kept 20 years or 8 years after the patient s death if patient died while in the care of the organisation. 30 from date of diagnosis, including deceased patients Guidance for best practice: the employment of counsellors and psychotherapists in the NHS, British Association for Counselling and Psychotherapy (BACP) NB. Those (counsellors) working within the NHS may be obliged to make counselling entries onto the patient s medical records or in a case file. These records are subject to the retention periods in this schedule. See Note 1. Derives from CJD Incidents Panel. See Note 1. 2 Lists sent to GRO on a monthly basis. Retain for 2 Likely to have archival value. See Note 1. years. 18

19 by the hospital, where they exist in paper format Dental epidemiological surveys Dental, ophthalmic and auditory screening records including Orthodontic Records and Models De-registered patients (received by PCT s) records for Diagnostic Image Data (for diagnostic imaging undertaken in the private sector under contract to the NHS or private providers treating patients on Death registers prior to lists sent to GRO offer to Place of Deposit for adults. For children 11 years or up to their 25 th birthday, whichever is the longer. Hospital Records Adult records retain for 8 years Children and young people Retain until the patient s 25 th birthday or 26 th if young person was 17 at conclusion of treatment, or 8 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain the records for a longer period. Records for de-registered patients, which are received by the PCT, should be retained for at least 10 years. After the retention period has elapsed a decision must be taken by the PCT as to whether to destroy the records or retain them further. Retain for the life of the National Diagnostic Imaging Services Contract and then return the data to the NHS after which the retention period in this retention schedule will apply. Derived from British Dental Association. Destroy under confidential conditions. Please refer to the Trust s Waste Derived from National Diagnostic Imaging Services Contract; Records Management: NHS Code of Practice. Destroy under confidential conditions. Please refer to the Trust s Waste 19

20 behalf of the NHS) Diaries health visitors, district nurses and Allied Health Professionals Diaries Community Midwives 2 after the end of the year to which the diary relates. Patient information should be transferred to the patient record. Any notes made in the diary as an aide memoire must also be transferred to the patient record as soon as possible. 7 after the end of the year to which the diary relates (as advised by LSA). Patient information should be transferred to the patient record. Any notes made in the diary as an aide memoire must also be transferred to the patient record as soon as possible. Retained diaries will be held centrally and securely with Midwifery Managers. Did not attend (DNA) see DNA below Dietetic and nutrition Discharge books (paper format) Discharge nursing team assessments of homes and nursing Should an investigation arise relating to a particular midwife, then his / her diary will need to retained for 25 years (as advised by LSA). For the period of time appropriate to the patient/specialty, e.g. children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. 8 after the last entry Likely to have archival value. See Note 1. For the period of time appropriate to the patient/specialty, e.g. children s records should be retained as per the retention period for the records 20

21 homes. NB The documents should be part of the patient record as they relate to the discharge of the patient District nursing records DNA (health records for patients who did not attend for appointments as outpatients) of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. For the period of time appropriate to the patient/specialty, e.g. children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. Where there is a letter or correspondence informing the healthcare professional/organisation that has referred the client/patient/service user that the patient did not attend and that no further appointment has been given, so this information is also held elsewhere. Retain for 2 years after the decision is made. Where there is no letter or correspondence informing the healthcare professional/organisation that has referred the client/patient/service user that the patient did not attend and that no further appointment has been given. Retain for the period of time appropriate to the patient/specialty, e.g. children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years 21

22 Donor records (blood and tissue) Drug trials, records (see Research records) Duplicate patient record notification forms (NHS Direct) Electrocardiogram (ECG) records Endoscopy Records including: Sterilix Endoscopic Disinfector Traceability Strips, Traceability Stickers for PEG/Stents (Endoscopy) Family planning records (see also Contraception and Sexual Health Records) after the patient s death if the patient died while in the care of the organisation. 30 post transplantation Derived from the Committee on Microbiological Safety of Blood and Tissues for Transplantation (MSBT); guidance issued in See Note 1. 2 years after the decision of whether or not to merge unless there is a business need to retain for longer. 7 NB. Each chart should be labelled with the patient s name and unique identifier. Any oversized charts could then be stored separately where a report is written into the health records. Retain for standard retention periods i.e. 8 years for adults and in the case of children and young people retain until the patient s 25 th birthday or 26 th if young person was 17 at conclusion of treatment, or 8 years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain the records for a longer period. For adult records - 10 after last entry. For clients under 18 retain until 25 th birthday or for 10 years after last entry, whichever is the longer i.e. records for clients aged should be retained until age 25 (i.e. still retained for at least 10 years). Records of deceased persons Derived from Clinical Standards Committee, Faculty of Sexual Health and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists. NB. The longest license period for a contraceptive device is 10 years. 22

23 Family Health Service Appeals Authority tribunal and case files Forensic medicine records (including pathology, toxicology, haematology, dentistry, DNA testing, post mortems forming part of the Coroner s report, and human tissue kept as part of the forensic record) should be retained for 8 years after death. 10 case files Decision records until individual s 80 th birthday For post-mortem records which form part of the Coroner s report, approval should be sought from the Coroner for a copy of the report to be incorporated in the patient s notes, which should then be kept in line with the specialty, and then reviewed. All other records retain for 30 years. See Note 1. The Retention and Storage of Pathological Records and Archives (3 rd edition 2005) guidance from the Royal College of Pathologists and the Institute of Biomedical Science: Human Tissue Act See Note 1. See also Human tissue, Post mortem registers. Genetic records 30 from date of last attendance The Royal College of Pathologists endorses the Code of Practice and Guidance of the Advisory Committee on Genetic Testing (1997) and its recommendations on storage, archiving and disposal of specimens and records related to human testing services (genetics) offered and supplied direct to the public. Those who intend to offer such services should follow its guidance. Genito Urinary Medicine (GUM). Includes sexual health records. For adult records - 10 after last entry. For clients under 18 retain until 25 th birthday or for 10 years after last entry, whichever is the longer i.e. records for clients aged should be retained until age 25 (i.e. still retained for at See Note 1. Derived from Clinical Standards Committee, Faculty of Sexual Health and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists. Destroy under confidential conditions. Please refer to the Trust s Waste 23

24 GP records, including medical records relating to HM Armed Forces or those serving a period of imprisonment least 10 years). Records of deceased persons should be retained for 8 years after death. See also Guidance on the Retention and Disposal of Hospital Notes, British Association for Sexual Health and HIV (BASHH) servicespec/guidance_retention_disposal_notes_ 0606.pdf GP Records, wherever they are held, other than the records listed below retain for 10 years after death or after the patient has permanently left the country unless the patient remains in the European Union. In the case of a child if the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the advice of clinicians should be sought as to whether to retain the records for a longer period. Maternity records 25 years after the last live birth. Records relating to persons receiving treatment for a mental disorder within the meaning of the Mental Health Act years after the date of the last contact; or 10 years after patient s death if sooner. NB. GPs may wish to keep mental health records for up to 30 years before review. They must be kept as complete records for the first 20 years but records may be summarised and kept in summary format for the additional 10 year period. Derived from the Limitation Act 1980, Congenital Disabilities (Civil Liability) Act 1976, and Consumer Protection Act Royal College of Psychiatrists. 24

25 Records relating to those serving in HM Armed Forces The Ministry of Defence (MoD) retains a copy of the records relating to service medical history. The patient may request a copy of these under the Data Protection Act (DPA), and may, if they choose, give them to their GP. GPs should also receive summary records when ex-service personnel register with them. What GPs do with them then is a matter for their professional judgement, taking into account clinical need and DPA requirements they should not, for example, retain information that is not relevant to their clinical care of the patient. Records relating to those serving a prison sentence see also Prison Health Records (below) for guidance on scanning of hospital letters. Electronic patient records (EPRs) must not be destroyed, or deleted, for the foreseeable future. Not to be destroyed. This refers to GP records of serving military personnel that were in existence prior to them enlisting. Following the death of the patient, the records should be retained for 10 years after their death. Not to be destroyed. This refers to GP records of serving prisoners that were in existence prior to their imprisonment. After their death, the records should be retained for 10 years. Good Practice Guidelines for General Practice Electronic Patient Records (version 3.1) Health visitor records Homicide/ serious untoward incident records Hospital acquired infection records 10. Records relating to children should be retained until their 25 th birthday. 30 See Note

26 Hospital records (i.e. other non-specific secondary care records that are not listed elsewhere in this schedule) Human fertilisation records, including embryology records 8 after conclusion of treatment or death Treatment Centres The following retention periods apply to data held by clinics as established by HFEA Direction D 1992/1: 1. Where it is known that a birth has resulted from treatment 25 years after the child s birth. 2. Where it is known that no birth has resulted from treatment 8 years after conclusion of treatment. 3. Where the outcome of treatment is unknown 50 years after the information was first recorded. Storage centres Where gametes, etc have been used in research, records must be kept for at least 50 years after the information was first recorded. Derived from HFEA Data Protection Policy Version 2 Release Date 27/07/ See Note 1. Directions given under the Human Fertilisation and Embryology Act 1990, 24 January 1992 (this Act is subject to review by the Government Human tissue (within the meaning of the Human Tissue Act Research centres Records are to be kept for 3 years from the date of final report of results/conclusions to Human Fertilisation and Embryology Authority (HFEA) For post-mortem records which form part of the Coroner s report, approval should be sought from the Coroner for a copy of the report to be This applies to centres in respect of information which they are directed to record and maintain under a storage licence. See Note 1. 26

27 2004) see also Forensic medicine Immunisation and vaccination records Intensive Care Unit charts Joint records replacement Learning difficulties (records of patients with) NB. Specific Learning Difficulty is where a person finds one particular thing difficult but manages well in incorporated in the patient s notes, which should then be kept in line with the specialty, and then reviewed. All other records retain for 30 years. For children and young people retain until the patient s 25 th birthday or 26 th if the young person was 17 at conclusion of treatment. All others retain for 10 years after conclusion of treatment. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. 10 For joint replacement surgery the revision of a primary replacement may be required after 10 years to identify which prosthesis was used. Only need to retain minimum of notes with specific information about the prosthesis for the full 10 years. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. Consumer Protection Act (CPA) 1987 & Section 11A (3) Limitation Act 1980 (in accordance with section 4 CPA). See Note 1. Derived from Royal College of Psychiatrists. 27

28 everything else. Learning Disabilities NB. A general learning disability is not a mental illness it is a life-long condition, which can vary in degree from mild to profound. Macmillan (cancer care) patient records community and acute Mammography Screening (mammograms reports) and Maternity (all obstetric and midwifery records Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. Normal Packet 9 after date of final attendance. Screen detected cancers Indefinitely. Interval cancers Indefinitely. Interesting cases Indefinitely. Research Cases 15 after date of final attendance. Age Trial Cases 9 after date of final attendance. Deaths 9 after date of final attendance. Where product liability is involved 11. NB. Retention periods should be calculated from the end of the calendar year following the conclusion of treatment or the last entry in the record. Derived from BFCR (06) 4 Royal College of Radiologists. Consumer Protection Act after the birth of the last child. For additional guidance see Records Management: NHS Code of Practice Part 2 28

29 including those of episodes of maternity care that end in stillbirth of where the child later dies) Medical illustrations (see Photographs) Mental Health Records Child & Adolescent (includes clinical psychology records) not listed elsewhere in this schedule. Mentally disordered persons (within the meaning of any Mental Health Act) Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. 20 years from the date of last contact, or until their 25 th /26 th birthday, whichever is the longer period. Retention period for records of deceased persons is 8 years after death. 20 years after the date of last contact between the patient/client/service user and any health/care professional employed by the mental health provider, or 8 years after the death of the patient/client/service user if sooner. NB. Mental health organisations may wish to keep mental health records for up to 30 years before review. Records must be kept as complete records for the first 20 years in accordance with this (Joint Position on the Retention of Maternity Records) devised by: British Paediatric Association, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Derived from the Mental Health Act 1983 and its successors and the Royal College of Psychiatrists. When the records come to the end of their retention period, they must be reviewed and not automatically destroyed. Such a review should take into account any genetic implications of the patient s illness. If it is decided to retain the records, they should be subject to regular review. 29

30 Microfilm/microfiche records relating to patient care retention schedule but records may then be summarised and kept in summary format for the additional 10-year period. This retention period has been left intentionally flexible to allow organisations to determine locally in collaboration with clinicians which option to follow as some organisations have storage problems and are unable to retain for longer than 20 years. The records of all mentally disordered persons (within the meaning of the MH Act) are to be retained for a minimum of 20 years irrespective of discipline e.g. Occupational Therapy, Speech & Language Therapy, Physiotherapy, District Nursing etc). Social services records are retained for a longer period. Where there is a joint mental health and social care trust, the higher of the two retention periods should be adopted. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient May have archival value. See Note 1. died while in the care of the organisation. Midwifery records 25 after the birth of the last child Midwives rules and standards (rule 9) Mortuary registers (paper format) 10 See Note 1. 30

31 Music therapy records Neonatal screening records Nicotine Replacement Therapy (dispensed as smoking cessation aid) Notifiable diseases book Occupational health records (staff) Health records for classified persons under medical surveillance Personal exposure of an identifiable employee monitoring record Personnel health records under occupational Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation unless there are clinical indications to keep them for longer. 6 3 after termination of employment unless litigation ensues 50 from the date of last entry or age 75, whichever is longer. 40 from date of exposure See above (reg. 10 (5)) See Note 1. Control of Substances Hazardous to Health Regulations 2002 (reg. 24(3)) See Note from date of last entry Ionising Radiation Regulations 1999 (reg. 11 (3)) See Note 1. 31

32 surveillance Radiation dose records for classified persons Occupational therapy records Occupationally Related Diseases e.g. asbestosis, pneumoconiosis, byssinosos) Oncology (including radiotherapy) Operating theatre lists (paper) Operating theatre registers Orthoptic records 50 from the date of last entry or age 75, whichever is longer. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. See above (reg. 19 (3) (a)) See Note after date of last entry in the record. Derived from the British Thoracic Society s Occupational and Environmental Lung Disease Specialist Advisory Group. 30 NB. Records should be retained on a computer database if possible. Also consider the need for permanent preservation for research purposes. 4 (for those lists that only exist in paper format and are the sole record). 48 hours (for prints taken from computer records). BFCO (96)3 issued by the Royal College of Radiologists with the support of the Joint Council for Oncology. See Note 1. Likely to have archival value. See Note 1. 8 after the year to which they relate Likely to have archival value. See Note 1. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the 32

33 Outpatient lists (paper format) Paediatric records (see Children and young people) Parent-held records (i.e. records for sick/ill children being cared for at home by community teams NOT the records of newborn children. These records are NHS records that belong to clinical staff but which are held by the parent. Photographs (where the photograph refers to a particular patient it should be treated as part of the health record. NB. In the context of the Code of Practice a photograph is a print taken with a camera and retained in the patient record. record or 8 years after the patient s death if patient died while in the care of the organisation. 2 after the year to which they relate At the end of an episode of care the NHS organisation responsible for delivering that care and compiling the record of the care must make appropriate arrangements to retrieve parent-held records. The records should then be retained until the patient s 25 th birthday or 26 th birthday if the young person was 17 at the conclusion of treatment, or 8 years after death. Retain for the period of time appropriate to the patient/specialty, e.g. Children s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after the patient s death if patient died while in the care of the organisation. Unless there is a clinical reason for retaining the digital image and a print is placed on the patient s record, there is no requirement to retain the digital image. 33