Non Clinical and Clinical Records Retention Schedule · referred to for the current version of the...

Status: Issue 3 Issue date: 13 April 2015 Approved by: Executive Team Review by date: 13 April 2016

Owner: Head of Health Records Policy Number: ABHB/IM&T/0407

Aneurin Bevan University Health Board

Non Clinical and Clinical Records

Retention Schedule

N.B. Staff should be discouraged from printing this document. This is to avoid

the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document.

Aneurin Bevan University Health Board ABHB/IM&T/0407 Title: Non-Clinical and Clinical Records Retention Schedule Owner: Head of Health Records

Status: Issue 3 Issue date: 13 April 2015

Approved by: Executive Team Review by date: 13 April 2016

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NON-CLINICAL AND CLINICAL RECORDS RETENTION SCHEDULE

CONTENTS

1 POLICY STATEMENT ........................................................................................ 4

2 INTRODUCTION ................................................................................................ 4

3 RETENTION ....................................................................................................... 5

4 LEGISLATION .................................................................................................... 6

5 Non-Clinical Record Types & Retention Periods: - Audit Reports 10 - Building, Estates & Property Management 10 - Contracts 12 - Contractor Records 12 - Corporate 13 - Equipment Records 14 - Financial 15 - Forms/Certificates/Registers 17 - General 18 - Hazard Notices 18 - Health & Safety/Risk Management 18 - Hotel Services 18 - Human Resources 18 - IT 20 - Salaries/Pension Records 20 - Supplies Department/Stores/Contracts 21 - Miscellaneous other 22 6. Clinical Record Types & Retention Periods: 23 - Accident & Emergency Records /Registers 23 - Adoption (includes Preadoption) 23 - Admission Books Ward 23 - Ambulance Records 23 - Audiology 23 - Audit Trails (Electronic Health Records) 24 - Birth Notification 24 - Blood Gas Results 24 - Chaplaincy Records 24 - Child Health Records 24 - Child Protection Register 24 - Clinical Audit Records 24




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- Clinical Diaries 24 - Community Records - Dental & Ophthalmic 25 - Contraception & Sexual Health 25 - Controlled Drug Documentation 25 - Creutzfeldt-Jakob Disease - Hospital & GP 25 - Death - cause of, Certificate Counterfoils 25 - Dental Epidemiological Surveys 25 - Dental, Ophthalmic & Auditory Screening Records (incl. Orthodontics) 26 - Dietetic & Nutrition 26 - District Nursing Records 26 - DNA (health records for patients who Did Not Attend) 26 - Donor Records (blood and tissue) 27 - Electrocardiogram Records 27 - Electronic Patient Records 27 - Endoscopy Records 27 - Family Planning Records 27 - Genetic Records 28 - Genito-Urinary Medicine 28 - GP Records (and medical records relating to HM Armed forces/Prisons) 28 - Health Records - persons under medical surveillance 29 - Health Visitor Records 29 - Homicide/Serious Untoward Incident Records 29 - Hospital Acquired Infection Records 29 - Hospital Records - non specific 29 - Human Fertilisation Records 30 - Human Tissue Records 30 - Immunisation & Vaccination Records 30 - Intensive Care Unit Charts 31 - Joint Replacement Records 31 - Laboratory Records 31 - Learning Difficulties (patient records) 33 - MacMillan Cancer Care Records 33 - Mammography Screening Records 34 - Maternity (all obstetric and midwifery records) 34 - Mental Health Act Administration Records 34 - Mental Health Records & CAMHS 34 - Microfilm/Microfiche Records 35 - Mortuary Registers 35 - Music Therapy Records 35 - Neonatal Screening Records 35 - Occupational Health Records (staff) 35 - Occupational Related Disease Records 35




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- Occupational Surveillance Health Records 35 - Occupational Therapy Records 35 - Oncology Records 35 - Operating Theatre Lists 36 - Operating Theatre -Recovery Room Registers 36 - Orthoptic Records 36 - Outpatient Lists 36 - Parent Held Records 36 - Patient Held Records 36 - Patient Information Leaflets 36 - Patient Surveys 36 - Phone Message Books 36 - Photographs 37 - Physiotherapy Records 37 - Podiatry Records 37 - Police Statements 37 - Private Patient Records 37 - Psychology Records 38 - Psychotherapy Records 38

- Psychiatric Records 38 - Records of destruction 38 - Referral letters (where care is not accepted) 38 - Research Records 38

- Scanned Records 40 - Speech & Language Therapy Records 40 - Suicide Records 40 - Surgical Appliance Records 40

- Transplantation 40 - Ultrasound 40

- Video Records/ Voice Records 41 - Vulnerable Adults 41 - X-ray Registers 41 - X-ray films and other modalities 42 - X-Ray Referral/Requests cards 42 - Wards Admission/Discharge Books 42 7 APPENDIX A .................................................................................................... 46 APPENDIX B ………………………………………………………………………… 45 APPENDIX C………………………………………………………………………… 46




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1 POLICY STATEMENT

This policy complies with the Welsh Assembly’s Guidelines WHC (2000) 71 Health Circular: For the Record – Managing Records in NHS Trusts and Health Authorities and the Department of Health - Records Management Code of Practice. The Circular:

1. Sets out the legal obligations for all NHS Bodies to keep proper records 2. Outlines the action required from Chief Executives, Senior Managers, Line Managers and

Supervisors to fulfil these obligations 3. Explains the requirements for the selection of records for permanent preservation 4. Lists suggested minimum periods for the Retention of NHS Records

The aim is to minimise record storage and retrieval, improve the standard of record keeping and ensure clinical information requirements are maintained. This Policy applies to all records held within the Acute, Community, Child Health, Mental Health and Learning Disability Services. This policy is applicable to all records whether they are in paper format, scanned or electronic records (see Appendix B). All NHS records are public records under the terms of the Public Records Act 1958, which confers a statutory duty on Trusts/Health Boards for the safekeeping and eventual disposal of the records as detailed in the Department of Health & Guidance Records Management: NHS Code of Practice and the requirements of the Freedom of Information Act (FOIA) 2000. The Chief Executive and Senior Managers are personally accountable for the quality of records management. Senior Managers are responsible for ensuring that staff are adequately trained and apply the appropriate guidelines. Individual members of staff are responsible for any records they create or use. This Policy also takes into account the Department of Health & NHS Code of Practice 2009 revised policy.

2 INTRODUCTION

The Public Records Act 1958 requires that there is a systematic and planned approach to the management of records within an organisation from their creation and maintenance to their ultimate disposal. Records are a valuable resource because of the information they contain. High-quality information underpins the delivery of high-quality evidence-based healthcare, and many other key service deliverables. Information has most value when it is accurate, up to date and accessible when it is needed. An effective records management service ensures that information is properly managed and is available whenever and wherever there is a justified need for that information, and in whatever media it is required. Information may be needed:

to support patient care and continuity of care;

to support day-to-day business which underpins the delivery of care;

to support evidence-based clinical practice;




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to support sound administrative and managerial decision making, as part of the knowledge base for NHS services;

to meet legal requirements, including requests from patients under subject access provisions of the Data Protection Act or the Freedom of Information Act;

to assist clinical and other types of audits;

to support improvements in clinical effectiveness through research and also to support archival functions by taking account of the historical importance of material and the needs of future research; or

to support patient choice and control over treatment and services designed around patients. .

The Caldicott Guardian is responsible for approving and ensuring that national and local guidelines and protocols on the handling and management of confidential personal information are in place. Ownership and copyright of NHS records as a rule lie with the NHS Board, not with any individual employee or contractor. The key statutory requirement for compliance with records management principles is the Data Protection Act 1998. It provides a broad framework of general standards that have to be met and considered in conjunction with other legal obligations. The Act regulates the processing of personal data, held both manually and on computer. It applies to personal information generally, not just to health records, therefore the same principles apply to records of employees held by employers, for example in finance, personnel and occupational health departments bodies likely to comment on records management performance include the Health Service Ombudsman when investigating a complaint, and the Information Commissioner when investigating alleged breaches of Data Protection or Freedom of Information legislation or in promoting the Lord Chancellor’s Code of Practice on Records Management under section 46 of the Freedom of Information Act

3 RETENTION

This policy is based on Welsh Health Circular WHC (2000) 71 For the Record – Managing Records in NHS Trusts and Health Authorities which details the legal minimum recommended periods for the retention and destruction of records and the Department of Health Code of Practice on the Retention of Records. A record of the destruction of records, showing their reference, description and date of destruction should be maintained and preserved by the Records Manager, so that the organisation is aware of those records that have been destroyed and are therefore no longer available. Disposal schedules would constitute the basis of such a record. If a record due for destruction is known to be the subject of a request for information, or potential legal action, destruction should be delayed until disclosure has taken place or, if the authority has




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decided not to disclose the information, until the complaint and appeal provisions of the Freedom of Information Act have been exhausted or the legal process completed Health Records Destruction All records falling into the category of being selected for destruction will be destroyed after meeting the following criteria.

All retention categories have been complied with

Records will be identified either by manual or computer methodology

Records will be physically checked to ensure that there are no entries relating to a later date

All health records will be manually checked to ensure that they contain no Advanced Directives (Living Wills)

Health Records will be marked as destroyed on the relevant computer systems on which details of the patient records are held e.g. Myrddin, Epex, EMIS, CCIS etc

Records for destruction will be destroyed in accordance with the appropriate Confidential Waste Policy.

4 LEGISLATION This policy and the guidelines on retention recognise and take into account such documentation as:

The Abortion Regulations 1991

The Access to Health Records Act 1990

The Access to Medical Reports Act 1988

Administrative Law

The Blood Safety and Quality Regulations 2005 – Directive 2002/98/EC of the European Parliament and of the Council of 27 January 2003 – Commission Directive 2005/61/EC of 30 September 2005

The Census (Confidentiality) Act 1991

The Civil Evidence Act 1995

The Common Law Duty of Confidentiality – Confidentiality: NHS Code of Practice

The Computer Misuse Act 1990

The Congenital Disabilities (Civil Liability) Act 1976

The Consumer Protection Act (CPA) 1987

The Control of Substances Hazardous to Health Regulations 2002

The Copyright, Designs and Patents Acts 1990

The Crime and Disorder Act 1998




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The Data Protection Act (DPA) 1998 – The Data Protection (Processing of Sensitive Personal Data) Order 2000

Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the Community Code Relating to Medicinal Products for Human Use

The Disclosure of Adoption Information (Post-Commencement Adoptions) Regulations 2005

The Electronic Communications Act 2000

The Environmental Information Regulations 2004

The Freedom of Information Act (FOIA) 2000

The Gender Recognition Act 2004 – The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) (No. 2) Order 2005

The Health and Safety at Work Act 1974

The Human Fertilisation and Embryology Act 1990, as Amended by the Human Fertilisation and Embryology (Disclosure of Information) Act 1992

The Human Rights Act 1998

The Limitation Act 1980

The NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000

The Police and Criminal Evidence (PACE) Act 1984

The Privacy and Electronic Communications (EC Directive) Regulations 2003

Public Health (Control of Diseases) Act 1984 and Public Health (Infectious Diseases) Regulations 1988

The Public Interest Disclosure Act 1998

The Public Records Act 1958

The Radioactive Substances Act 1993 – The High-activity Sealed Radioactive Sources and Orphan Sources Regulations

The Re-use of Public Sector Information Regulations 2005

The Sexual Offences (Amendment) Act 1976 Subsection 4(1) as Amended by the Criminal Justice Act 1988




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Non – Clinical Record Types and Retention Periods

SERVICE/DEPARTMENT RECORD TYPE/SUB TYPE RETENTION PERIOD (YRS) NOTES

Audit Reports Audit Reports – original documents (e.g. Organisational Audits, Records Audits, System Audits) Internal and External

2 years From completion of the audit

Audit Reports – (including Management Letters, VFM reports and system/final accounts memorandum)

2 years After formal clearance by Statutory Auditor

Building Estates & Property Management

Buildings and engineering works, inclusive of major projects abandoned or deferred – town and country planning matters and all formal contract documents e.g. executed agreements, conditions of contract, specifications, “as built” record drawings and documents on the appointment and conditions of engagement of private buildings and engineering consultants

30 years

Buildings and engineering works, inclusive of major projects, abandoned or deferred – key records, e.g. final accounts, surveys, site plans, bills of quantity

30 years

Buildings – papers relating to occupation of the building (but not health and safety information)

3 years after occupation ceases

Contracts – financial Approval plans – 15 years Approved suppliers lists – 11 years

Deeds of Title Retain while organisation has ownership of the building unless a Land Registry certificate has been issued, in which case the deeds should be placed in an archive.

If there is no Land Registry certificate, the deeds should pass on with the sale of the building




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Building Estates and Property Management

Drawings – plans and buildings (architect signed, not copies)

Lifetime of the building to which they relate

(cont) Engineering works – plan and building records

Lifetime of the building to which they relate

Equipment – procurement, use, modification and supply records relevant to production of products (diagnostics) or equipment

11 years See Products Liability

Equipment- instruments maintenance logs, records of service inspections

Lifetime of equipment

Estates - Approved Suppliers Lists 11 years Consumer Protection Act 1987

Estimates: including supporting calculations and statistics

3 years

Inspection Reports e.g. boilers, lifts etc. Lifetime of installation Normally retain for the lifetime of an installation. However, it is necessary to assess whether obligations incurred during the lifetime may be invoked afterwards, in which case a judgement must be made. If there is any measurable risk of a liability in respect of installations beyond their operational lives, records of this kind should be retained indefinitely

Inventories (not in current use) of items having a life of less than 5 years

1.5 years

Inventories Keep until next inventory Furniture, medical and surgical equipment not held on store charge and with a minimum life of 5 years

Land Survey/Registers * Recommended – permanent preservation

Leases * Recommended – permanent preservation

Manuals – operating Lifetime See Inspection reports

Manuals – policy and procedure * Recommended – permanent preservation

Maps * Recommended – permanent preservation

Mortgage documents (acquisition, transfer and disposal)

6 years after repayment




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Building Estates and Plans – Building (As built) * Recommended – permanent preservation

Property Management Plans – Building (Detailed) Lifetime See Inspection reports

(cont) Plans – Engineering Lifetime See Inspection reports

Products Liability 11 years Consumer Protection Act 1987

Property Acquisitions Dossiers Permanent

Property Disposal Dossiers Permanent

Structure Plans (LA’s) Lifetime of a building Organisational charts i.e. the structure of the building plans

Surveys – building and engineering works * Recommended – permanent preservation

Tenancies Agreement 7 years Government Regulations

Title Deeds See Deeds of Title

Contracts Contracts - non sealed (property) on termination

6 years The Limitation Act, 1980

Contracts - non sealed (other) on termination

6 years The Limitation Act, 1980

Contracts - sealed 15 years Contracts under seal and associated records should be kept for a minimum of 15 years

Contracts – financial 15 years 11 years

Approval files Approved suppliers lists

Project files (over £100,000) on termination - including abandoned or deferred projects

6 years

Project files (less than £100,000) on termination

2 years

Project Team Files -summary retained

3 years

Site Files As per contracts

Specifications

6 years The Limitation Act 1980




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Contractor Records Ophthalmic Opticians, Ophthalmic Medical Practitioners, Pharmacists, Pharmacy Premises, General Optical Council amendments to the register, previous Pharmacy rotas and supporting information (prior to 2005 – new regulations), copies of previous Pharmacy and Ophthalmic local lists, correspondence relating to pharmacies supplying oxygen and visiting Residential/Nursing Homes (prior to new regulations).

7 years NHS (General Ophthalmic Services )Regs 1986: A contractor shall keep a proper record in respect of each patient to whom he provides general ophthalmic services, giving appropriate details of sight testing. Subject to paragraph 8(5) a contractor shall retain all such records for a period of 7 years and shall during that period produce them when required to do so by the Health Board or the Minister for Health.

Doctors Postgraduate Educational Allowance/ Personal Development Plan files and supporting general correspondence

GP seniority – (prior to 2004 – new regulations)

Corporate Agendas See meeting papers

Annual Corporate Reports 3 years

Assembly/Parliamentary Questions/MP Enquiries

10 years As these documents include all information provided by the organisation in response to an Assembly /Parliamentary Question e.g. background note to the Minister or the Minister may amend the response) all of which may not be used in the response therefore it will not be in the public domain they must be destroyed under confidential conditions.

History of organisation or predecessors, its organisation and procedures

30 years Archivist should be contacted

Complaints

See Litigation dossiers

Copyright declaration forms

6 years

Data input forms 2 years Where data/information has been input into a computer system




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Corporate (cont) Diaries - desk/administration – office – on completion

1 year

Freedom of Information requests 3 years after full disclosure and 10 years if information is redacted or the information requested is not disclosed

History of organisation or predecessors its organisation and procedures e.g. establishment order

30 years

Hospital (trust) services i.e. service that the Trust provides e.g. catering, hotel services

10 years

Indices Registry lists of public records marked for permanent preservation or containing the record of management of public records 30 years

File and document lists where public records or their management are not covered – 30 years

Litigation Dossiers (complaints including accident reports) Record/documents relating to any form of litigation

10 years Where a legal action has commenced, keep as advised by legal representatives

Meeting and minutes papers of major committees and sub-committees (master copies)

30 years

Meetings and minutes papers (other, including reference copies of major committees)

2 years

Minutes – reference copies

1 year




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Corporate (cont) Press cuttings 1 year

Press Releases 7 years

Public Consultations e.g. about future provision of services

5 years

Quality and Outcomes Framework 2 years

Reports (major) Permanent

Research ethics committee records 3 years from date of decision

Serious Incident Files * These documents must be considered for permanent preservation.

Trust documents without permanent relevance

6 years

Equipment Records Equipment/instruments/maintenance logs, records of service inspections Procurement, use, modification and supply records relevant to production of products (diagnostics) or equipment

Lifetime of equipment 11 years

See products – Liability Hazard Notices – Local decisions etc If the records relate to vehicles (ambulances, responder cars, fleet vehicles etc.,) and where the vehicle no longer exists, providing there is a record that it was scrapped, the records can be destroyed

Financial Accounts – Annual (Final – one set only)

Permanent

Accounts – Cost

3 years

Accounts – Working Papers

3 years

Accounts – Minor records (pass books: paying-in slips; cheque counterfoils; cancelled/discharged cheques (other than cheques bearing printed receipts - see Receipts); accounts of petty cash expenditure; travelling and subsistence accounts; minor vouchers; duplicate receipt books; income records; laundry lists and receipts)

2 years from completion of audit




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Financial (cont) Audit Records (including Management Letters, VFM reports and system/final accounts memorandum) as advised by External Auditors

2 years After formal clearance by Statutory Auditor

Audit Records - original documents (as advised by External Auditors)


Bank Statements

2 years From completion of the audits

Benefactions 5 years after the end of the financial year in which the Health Board spends the monies or the gift in kind is accepted. Where the Benefaction Endowment Trust fund/capital/interest remains permanent records should be permanently retained.

Recommended permanent preservation

Bills, receipts and cleared cheques

6 years

Budget Variaments

6 years From completion of the last External audit

Budgets


Capital charges data


Capital paid invoices

6 years See Invoices

Cash Books


Cash Sheets





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Financial (cont) Charitable Funds 30 years

Company charities are required by company law to keep their accounts and accounting records for minimum 3 years but Charity Commission recommends 6 years. Non-Company charities must keep accounts and accounting records for 6 years (Part VI Charities Act, 1993) Although classed as exempt from The Public Records Act, it is appropriate to treat these records as if they are not exempt

Cost accounts

3 years after end of financial year to which they relate

Creditor payments


Debtors’ records – cleared


Debtors’ records – uncleared


Demand notes


Expense claims, including travel and subsistence claims and authorisations


Financial records See under individual headings. However, once the period of retention for audit purposes is complete (2 years from completion of audit), documents not required for permanent preservation may be destroyed provided a properly compiled microfilm record is retained for the remainder of the prescribed period, embodying a suitable certificate by the treasurer as to its accuracy and completeness. This does not apply to forms SD55 (ADP) and SD55J

Fraud Case Files/investigations

6 years




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Financial (cont) Fraud national proactive exercises

3 years

Funding data


Income and expenditure journals

6 years

Invoices 6 years after end of financial year to which they relate. Limitation Act 1980

Ledgers including cash books, ledgers, income and expenditure journals, nominal rolls etc


Mortgage documents (acquisition, transfer and disposal)

Permanent

Nominal rolls 6 years (maximum) As a general rule, it may be appropriate for only the current nominal roll and the immediately preceding roll to be kept

Payments


Payroll (ie list of staff in the pay of the organisation

6 years after termination of employments

Private Finance Initiative

30 years

Receipts

6 years The Limitations Act 1980

Receipts for registered and recorded mail


Superannuation accounts

10 years

Tax forms

6 years

VAT Records 6 years




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Forms/Certificates/ Registers

Abortion – Certificate A (For HSA1) and Certificate B (Emergency Abortion)

3 years Abortion Regulations 1991, Statutory Instrument No. 499

Body Release Forms

2 years

Deaths – Cause of, Certificate counterfoils

2 years

Forms – Surgical Appliances – AP1, 2, 3 and 4

2 years From completion of audit

Forms – Superannuation – SD55 (ADP) and SD55J (copies)

10 years Originals are sent to NHS Pensions Agency

FP10, TTO’s outpatient and private 2 years Electronic Patient Records will eventually hold all these details`

GMS1 forms (registration with GP)

3 years

Indices Permanent Registry lists may describe public records marked for permanent preservation, or contain the record of management of public records. They should in these cases be retained permanently. File-lists and document lists, where public records or their management are not covered, should be retained until they have no further administrative use

Receipt for registered and recorded delivery mail

1.5 years

General Quality Assurance Records

12 years

Research* Development (Scientific, Technological and Medical)

* These documents must be considered for permanent preservation.

Hazard Notices 5 years As per Solicitor’s advice




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Health and Safety/Risk Management

Accident Books 3 years After last entry

Accident Forms/Books 10 years Where legal action has been commenced, keep as advised by legal representatives

Accident Register (RIDDOR) 10 years Reporting of injuries, diseases and dangerous occurrences regulations, reg. 7; Social Security (Claims and Payments) Regulations, reg. 25

Close Circuit TV images 31 days As per the Information Commissioner’s Code of Conduct these need to be erased permanently

Hazard Notices As per Legal advice

Health and Safety Documentation 3 years

Incident Forms 10 years

Risk Assessments Retain the latest one until a further assessment replaces it

Serious Incident Files * Recommended – permanent preservation IRI Form, blue copy – Local decisions should be taken with regard to these.

Hotel Services Laundry Lists and Receipts


Record of custody and transfer of keys 2 years after last entry

Human Resources Advance Letters

6 years

CVs for non-executive directors (successful)

5 years Following term of office

CVs for non-executive directors (unsuccessful applicants)

2 years

Duty Rosters 4 years after the year to which they relate

Organisation or departmental rosters, not the ones held on the individuals record




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Human Resources (cont)

Establishment records - major (e.g. personal files, letters of appointment, contracts, references and related correspondence)

6 years Keep for 6 years after subject of file leaves service, or until subject's 70th birthday, whichever is the later. Only the summary needs to be kept to age 70' remainder of file can be destroyed 6 years after subject leaves service

Establishment records – minor (e.g. attendance books, annual leave records, duty roster, clock cards, timesheet)

2 years

FWH – Personal Record of Hours Actually Worked

0.5 years

Industrial Relations (not routine staff matters)

* Recommended for permanent preservation

Job advertisements

1 years

Job Applications (following termination of employment)

3 years

Job Descriptions (following termination of employment)

3 years

Letters of appointment

See Establishment records – major

Leavers Dossiers (provided summary retained)

6 years after individual has left. Summary to be retained until individual’s 70th birthday

or until after cessation of employment if aged over 70 years at the time. Summary should contain everything except attendance books, annual leave, duty rosters, clock cards, timesheets, study leave applications and training plans.

Personnel Files See Establishment records – major

Staff Records See Establishment records – major

Study Leave Applications 5 years

Subject Files * Recommended – permanent preservation




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Information Technology

Computerised records

The recommended minimum retention periods apply to both paper and computerised records, though extra care needs to be taken to prevent corruption or deterioration of the data. Re-recording/migration of data will also need to be considered as equipment and software become obsolete. For guidance, see the Public Record Office guidance, Management and Appraisal of Electronic Records (1998)

Documentation relating to computer programmes written in-house

Lifetime of software

Software Licences Lifetime of software

Patient Activity Data 3 years

Salaries/Pension Records

Expense claims 2 years From completion of audit

Pay Roll - full time medical staff 6 years For superannuation purposes authorities may wish to retain such records until the subject reaches benefit age

Pay Roll - other staff

6 years

PAYE Records

6 years

Pension Forms – all

7 years

Wages/Salaries Records 10 years For superannuation purposes authorities may wish to retain such records until the subject reaches benefit age

Salaries

See Wages

Superannuation Accounts

10 years

Superannuation Registers 10 years




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Time Sheets 2 years after the year to which they relate

NB Time sheets (for all individuals including locum doctors) held on the personnel record are minor records – 2 years Timesheets held elsewhere – i.e. on the ward retain for 6 months(as the master timesheet is held on the personnel file)

Time Sheets 6 months NB Relating to a group of Department e.g. Ward where the timesheets are kept as a tool to manage resources, staffing levels

Supplies Department/ Stores/Contracts

Advice notes 1.5 years

Agreements

See Contracts

Approval Files (Contracts)

* Recommended – permanent preservation

Approved Suppliers Lists

11 years Consumer Protection Act 1987

Delivery Notes

2 years After end of financial year to which they relate

Inventories (not in current use) of items having a life of less than 5 years

1.5 years

Maintenance contracts – routine

See contracts

Products – liability


Project Files (over £100,000) on termination – including abandoned or deferred projects

* Recommended – permanent preservation

Project Files (less than £100,000) on termination

6 years




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Project Team Files – summary retained

3 years

Requisitions

1.5 years

Site Files

See Contracts

Specifications


Stock Control Reports

1.5 years

Stores Records – major (stores, ledgers etc)

6 years

Supplies Records – minor (e.g. invitations to tender and inadmissible tenders, routine papers relating to catering and demands for furniture, equipment, stationery and other supplies

1.5 years

Tenders (successful)

See Contracts

Tenders (unsuccessful) 6 years The Limitation Act 1980

Miscellaneous Records

Biomedical Engineering Sterilix Endoscopic Disinfector Daily Water Cycle Test

11 years

Sterilix Endoscopic Disinfector daily Water Purge Test Nynhydrin Test

11 years

Close Circuit TV images 31 days As per the Information Commissioner’s Code of Conduct these need to be erased permanently

Close Circuit TV images




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Chaplaincy Records 2 years

Research & Development (scientific, technological and medical)

30 years All the organisation’s records associated with research and development and not individual trial records or information on patients.

External quality control records 2 years

Internal quality control records – relating to products

10 years

Nurses Training Records 30 years




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CLINICAL RECORD TYPES AND RETENTION PERIODS SERVICE/DEPARTMENT RECORD TYPE/SUB TYPE RETENTION PERIOD (YRS) NOTES

Accident and Emergency records (where these are stored separately from the main patient record)

Retain for the period of time appropriate to the patient/speciality, e.g. children’s A&E records should be retained as per the retention period for the records of children and young people.

Accident and Emergency Register

8 years after the year to which they relate

Local decisions should be made with regard to the permanent preservation of these records, in consultation with relevant health professionals and places of deposit

Adoption records (i.e. administrative records relating to the adoption process)

75th anniversary of the date of birth of

the child to whom it relates or, if the child dies before attaining the age of 18. 15 years beginning with the date of the 18

th birthday

See Pre-adoption records below

Pre-Adoption Records Records, where the NHS number has been changed following adoption, will be returned to the appropriate Child Health Team and they should be held 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

Until the patient’s 25th birthday, or 26th if young person was 17 at conclusion of treatment; or 8 years after patient’s death occurred before 18th birthday

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

Admission Books – Ward 8 years since last entry

Where they exist in paper format

Ambulance records- patient identifiable component

To include paramedic records made on behalf of the Ambulance Service

10 years for ALL Ambulance Clinical Records

Where 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




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Audiology records Retain for the period of time appropriate to the patient/speciality.

Audit trails (Electronic Health Records)

Organisations are advised to retain all audit trails until further notice

See Appendix B

Birth Notification Retain until the patients 25th birthday

or 26th if young person was 17 at

conclusion of treatment or 8 years after death

Blood gas results

Retain for the period of time appropriate to the patients/speciality eg children’s record 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 of 8 years after the patient’s death, if patient died while in the care of the organisation

Chaplaincy Records 2 years

Likely to have archival value

Child Health Records (notification of Visitors/New Entrants into a borough either from abroad or within the UK from Airports, the Home Office Immigration Centre and Housing Options Teams)

Database of notifications – entries should be retained for 2 years. Where the 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 years or 10 years after the patient’s death, if the patient died while in the care of the organisation.

This also applies to any other information that related 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. If the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the clinician should advise as to whether the records are retained for a longer period.




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Clinical Audit records 5 years

Clinical Diaries All types of clinical diaries – to include health visitors, district nurses and Allied Health Professionals

2 years after end of year to which diary relates.

Specific patient information should be transferred to the patient records. Any notes made in the diary as an “aide memoire” must also be transferred to the patient record as soon as possible after the event.

Community Records – Dental and Ophthalmic

11 years – adults Children – 11 years or up to their 25

th

birthday – whichever if the longer Adults – retain for 8 years Children – as per previous guidance

Includes auditory screening records and Orthodontic records and models 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.

Contraception and Sexual Health Records (including where a scan is undertaken prior to termination of pregnancy but the patient goes elsewhere for the procedure

8 years (in adults) or until 25th birthday

in a child (age 26 if entry made when young person was 17) or 8 years after death

Controlled drug documentation

Removed from Pharmacy Records

Requisitions – 2 years Registers and CDRB’s – 2 years from last entry Extemporaneous preparation worksheets – 13 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 CD’s – 7 years

NB Future regulations may increase the period of time for the storage of records. Please refer to Department of Health http://www.dh.gov.uk/en/index.htm and Royal Pharmaceutical Society of Great Britain Http://www.rpsgb.org.uk/ for up to date information

http://www.dh.gov.uk/en/index.htm

http://www.rpsgb.org.uk/




27


Death – Cause of, Certificate counterfoils

2 years

Dental epidemiological survey

30 years

Dental, ophthalmic and auditory screening records including Orthodontic Records and Models

Community Records Hospital Records

11 years for adults For children 11 years or up – until their 25

th birthday

Adult records – 8 years Children & Young People - Retain until the patients 25

th birthday or 26

th if

young person was 17 at conclusion of treatment or 8 years after death

British Dental Association guidance

Dietetic and nutrition

Parenteral nutrition

Retain for the period of time appropriate to the patient/speciality e.g. children’s records 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 death – if patient died while in the care of the organisation. 2 years

Guidance for Dietitians for Records and Record Keeping - BDA Original valid prescription should be kept in patient’s notes

District nursing records

Retain for the period of time appropriate to the patient/speciality e.g. children’s records 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 death – if patient died while in the care of the organisation.




28


DNA – (health records for patients who DID NOT ATTEND for appointments as outpatients

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 no further appointment has been given

Retain for the period of time appropriate to the patient specialty children’s records 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 death – if patient died while in the care of the organisation

Donor Records (blood and tissue)

30 years post transplantation Committee on Microbiological Safety of Blood and Tissues for Transplantation (MSBT); guidance issued 1996

Electrocardiogram (ECG) Records

7 years Each chart should be labelled with the patient’s name and unique identifier. Any over-sized charts could then be stored separately where a report is written into the health record.

Electronic patient records (EPR’s)

Must not be destroyed or deleted for the foreseeable future

See Appendix B for further information

Endoscopy Records

Retain for standard retention periods i.e. 8 years for adults and in the case of children and young people retain until the patients 25

th birthday or 26

th if

young person was 17 at conclusion of treatment or 8 years after death.

Including: Sterilix Endoscopic, Disinfector, Traceability Strips, Traceability Sticker for PEG/Stents If 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 long period.

Family Planning records

See also Contraception and Sexual Health Records

For records of adults retain for 10 years 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 16-17 should be retained for 10 years and records for clients under 16 should be retained until age 25

Records of deceased patients should be retained for 8 years after death.




29


Genetic records

30 years from date of last attendance 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 offered and supplied direct to the public.

Genito Urinary Medicine (GUM)

For records of adults retain for 10 years 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 16-17 should be retained for 10 years and records for clients under 16 should be retained until age 25 (i.e. still retained for at least 10 years) Records of deceased patients should be retained for 8 years after death.

Faculty of Sexual and Reproductive Healthcare (FRSH) of the Royal College of Obstetricians and Gynaecologists and British Association for Sexual Health and HIV (BASHH)

GP Records including medical records relating to HM Armed Forces or those serving a period of imprisonment

GP Records wherever they are held, other than the records list below should be retained for 10 years after death or after the patient has permanently left the country unless the patient remains in the EU. In the case of a child, if the illness or death could have genetic implications for the family of the deceased, the advice of the clinician should be sought as to whether the record is retained for a longer period

Maternity Records – 25 years after last live birth

Limitation Act 1980, Congenital Disabilities (Civil Liability) Act 1976, Consumer Protection Act 1987




30

Mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last contact– or 10 years after death – if sooner

Royal College of Psychiatrists – NB GP’s 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 may be summarised and retained in summary format for a further 10 years

GP Records including medical records relating to HM Armed Forces or those serving a period of imprisonment (cont)

Armed Forces Records relating to those serving a prison sentence

Records relating to those serving in HM Armed forces – The Ministry of Defence retains a copy of the records relating to service medical history. The patient may request a copy of these under the Data Protection Act and give them to their GP. GPs should also receive summary records when ex-Service personnel register with them. Not to be destroyed

Not to be destroyed 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 death. Refers to GP records of serving prisoners that were in existence prior to their imprisonment. Following the death of the patient the records should be retained for 10 years after death

Health Records – persons under medical surveillance

50 years from date of the last entry or age 75, whichever the longer

Health Visitor Records

10 years. Records relating to children should be retained until their 25

th

birthday

Homicide/serious untoward incident records

30 years

Hospital acquired infection records

6 years




31


Human fertilisation records, including embryology records

Human fertilisation records, including embryology records (cont)

Treatment Centres 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 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

Research Centre Records are to be kept for 3 years from the date of final report of results/conclusions to Human Fertilisation and Embryology Authority (HFEA)

HFEA Data Protection Policy Version 2 Release Date 27/07/2007 Directions given under the Human Fertilisation and Embryology Act, 1990 24 January 1992 (Act subject to review by Government). Applies to centres in respect of information which they are directed to record and maintain under a treatment/storage licence

Human Tissue (within meaning of the Human Tissue Act 2004)

For post mortems 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 speciality and then reviewed

All other records retain 30 years

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 2004




32


Intensive Care Unit charts

Retain for the period of time appropriate to the patient/speciality i.e. adult – 8 years, children and obstetrics 25 years, Mental Health 20 years from the date of last entry into the record

Joint replacement records

For joint replacement surgery the revision of a primary replacement may be required for the lifetime of the patient and there is a need to identify which prosthesis was used originally.

Local decision - Lifetime of the patient and 8 years after death*

*There is only a need to retain the minimum of notes with specific information about the original prosthesis for the lifetime of the patient

Laboratory Records Accreditation documents; records of inspections

10 years or until superseded Retention schedules are under review by the Royal College of Pathologists – check RCP website

Batch Records results (relating to products)


Blood gas results Retain for the period of time appropriate to the patient/specialty

Blood Donor records and tissue 30 years post transplantation

Blood for grouping, antibody screening and saving and/or cross matching

1 week at 4ºC

Cervical Screening slides

10 years

Day books and other records of specimens received by a laboratory

2 calendar years

Electrophoretic strips and immunofixation plates

5 years Unless digital images taken, in which case 2 years and stored as a photographic record

External quality control records 2 years

Foetal serum 30 years




33


Laboratory Records (cont)

Frozen tissue or cells for histochemical or molecular genetic analysis

10 years

Grids for electron microscopy 10 years

Human DNA 4 weeks after final report for diagnostic specimens. 30 years for family studies for genetic disorders (consent required)

Laboratory file cards or other working records of test results for named patients

2 calendar years

Microbiological cultures 24-48 hours after final report of a positive culture issued. 7 days for certain specified cultures – see RCPath document

Museum specimens(teaching collections) Stained slides

Permanently Depends on the purpose of the slide – see RCPath document

Consent of the relative is required if it is tissue obtained through post mortem

Newborn blood spot screening cards

5 years Parent should be alerted to the possibility of contact from researchers after this period and a record kept of their consent to contact response

Newborn - Body fluids /aspirates/ swabs

48 hours after the final report issued by lab

Paraffin block 30 years Then appraise for archival value+

Post Mortem Report copies Post Mortem reports

6 months Held in patients health record for 8 years after the patient’s death




34


Laboratory Records (cont) Records relating to investigation or storage of specimens relevant to organ transplantation semen or ova

30 years if not held with the health record

Records relating to donor or recipient sera

11 years post transplant

Results of antibody screening, grouping and other blood transfusion relate tests

30 yes to allow full traceability of all blood products used

EU Directive 2002/98/EC The Blood Safety an Quality Regulations 2005

Standard Operating Procedures (current and old)

30 years

Separated serum/plasma,stored for transfusion purposes

Up to 6 months

Serum following needlestick injury of hazardous exposure

2 years

Serum from first pregnancy booking visit

1 year

Wet tissue (representative aliquot or whole tissue or organ)

4 weeks after final report for surgical specimens

Whole blood samples, for full blood count

24 hours

Learning Difficulties (patient records)

Patients with Learning Difficulties Records

Retain for the period of time appropriate to the patient/speciality e.g. children’s records 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 death – if patient died while in the care of the organisation.

NB Specific Learning Difficulty is where a person finds one particular thing difficult but manages well in everything else 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 Royal College of Psychiatrists




35


Mammography Screening - Mammograms and reports

Normal Packet – 9 years after date of final attendance Screen detected cancers – Indefinitely Interval Cancers – Indefinitely Interesting Cases – Indefinitely Research Cases – 15 years after date of final attendance Age Trial Cases – 9 years after date of final attendance Deaths – 9 years after date of final attendance Where product liability – 11 years

NB Retention period should be calculated from the end of the calendar year following the conclusion of treatment or the last entry BFCR(06)4 Royal College of Radiologists

Maternity (all obstetric and midwifery records)

Includes those episodes of maternity care that end in stillbirth or where the child later dies

25 years after the birth of the last child

See Appendix A (devised by BPA, RCM, RCOG, and UK Central Council for Nursing, Midwifery & HV

Mental Health Act Administration Records

5 years NB There is no obligation to treat this type of mental health record as being part of a patient’s health record. Exceptions, are required if to be kept as evidence in actual or expected litigation

Mental Health Records & CAMHS

See further references for: Learning Difficulties Psychotherapy Psychology Records Psychiatric

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 death – if patient died while in the care of the organisation For children and young people – retain until 20 years after the last entry in the record or as a minimum until the patients 26

th birthday if they

were age 5 at the time of treatment– or 8 years after death if the patient died while in the care of the organisation.

When the records come to the end of their retention period they should be reviewed and this should take account of any genetic implications of the patient’s illness. If the records are to be retained they should be subject to regular review.




36


Microfilm/microfiche records relating to patient care

Retain for period of time appropriate to the patient/speciality

Mortuary registers

10 years Where exist in paper format

Music Therapy records

Retain for the period of time appropriate to the patient/speciality

Neonatal screening records

25 years

Occupational Health Records ( staff)

3 years after termination of employment unless litigation ensures

Occupational Surveillance Health Records

50 years from the date of last entry or age 75 – whichever is the longer

Control of Substances Hazardous to Health Regulations 2002 (reg. 24(3))

Occupationally Related Diseases e.g. asbestosis, pneumoconiosis, byssinosos

10 years after date of last entry in the record

British Thoracic Society’s Occupational & Environmental Lung Disease Specialist Advisory Group

Occupational therapy records

Retain for the period of time appropriate to the patient/speciality e.g. children’s records 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 death – if patient died while in the care of the organisation .

Oncology (including radiotherapy)

30 years Organisations which need to retain records for longer than 30 years should consult with their Local Place of Deposit. Consider permanent preservation Deceased patients – 8 years after death NB Records should be retained on a computer database if possible and also consider the need for permanent preservation for research purposes.




37


Operating Theatre Lists – paper

Operating Theatre - Recovery Room Registers

4 years 48 hours (for prints taken from computer records) 8 years

Lists that only exist in paper format and are the sole record must be retained Organisations which need to retain records for longer than 30 years should consult with their Local Place of Deposit. Consider permanent preservation

Orthoptic records

Retain for the period appropriate to the patient/speciality e.g. children’s records 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 death – if patient died while in the care of the organisation

Outpatient Lists

2 years after the year to which they relate

Parent Held Records

The records should be retained until the patients 25

th birthday or 26

th

birthday if the young person was 17 at conclusion of treatment or 8 years after death

Records of sick/ill children being cared for at home by community teams. NOT records of newborn children These records are NHS records that belong to clinical staff but which are held by the parent

Patient Held Records

At the end of an episode of care the Health Board will retrieve the patient held record and ensure that it is retained for the period appropriate to the specialty

Patient Information Leaflets

6 years After the leaflet has been superseded




38


Phone Message Books

2 years NB Any clinical information should be transferred to the patient health record

Photographs

Retain for the period of time appropriate to the patients/ speciality eg children’s record 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 of 8 years after the patient’s death, if patient died while in the care of the organisation.

NB In the context of the Code of Practice a “photograph” is a print taken with a camera and retained in the patient record 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.

Physiotherapy Records

Retain for the period of time appropriate to the patients/ speciality eg children’s record 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 of 8 years after the patient’s death, if patient died while in the care of the organisation

Podiatry Records

8 years from date of last attendance for adults, until the child’s 25

th

birthday if under 18 and 20 years for mentally disordered patients

The Society of Chiropodists & Podiatrists

Police Statements

10 years (congruent retention period as Incident Forms)

Made in the context of Accident and Emergency episodes. Statements are requested by Police to the A& E staff in relation to alleged injuries of or by patients coming through A & E




39


Private patient records admitted under section 58 of the National Health Service Act 1977 or section 5 of the National Health Service Act 1946

Although technically exempt from the Public Records Acts, it would be appropriate for authorities to treat such records as if they were not so exempt. See Hospital patient case records.

Private patient records admitted under section 58 of the National Health Service Act 1977 or section 5 of the National Health Service Act 1946

Psychology Records - clinical

30 years (local timescale) or 8 years after death if patient died while in the care of the organisation

Psychotherapy Records

20 years or 8 years after death if patient died while in the care of the organisation

Psychiatric Records

20 years from date of last attendance or 8 years after death if patient died while in the care of the organisation

Records of destruction

Record of destruction of individual health records (held on paper or on computer system)

Permanently BS ISO 15489

Referral letters (where care is not accepted)

Where letter detailing reason for non-acceptance goes to the referring organisation so that the information is held elsewhere Where there is no letter or correspondence

2 years from date of decision Retain for the period of time appropriate to the patients/ speciality eg children’s record 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




40

Health Act 1983) 20 years after the last entry in the record of 8 years after the patient’s death, if patient died while in the care of the organisation

Research Records

See overleaf




41


Clinical Trials of Investigational Medicinal Products Trial Master file

Research Ethics Committee Records

Trial Subjects Medical File

Marketing authorisation

Trial Subjects medical file

All other documentation pertaining to the trial

Responsibility of Sponsor and Chief Investigator to ensure that the documents are retained Ethics Committee shall retain all documents relating to a clinical trial on which it gives an opinion for :- Sponsor & Chief Investigator’s responsibility to ensure retained Holders must arrange for essential clinical trial documents (including case report forms) other than the health record to be kept by the owners of the data Retention of the documentation is the responsibility of the sponsor Responsibility of sponsor or subsequent owner to retain documents

5 years after conclusion of the trial Trial proceeds – 3 years from close Trial does not proceed – 3 years from the date of the opinion Five years after the conclusion of the Trial. 15 years after completion/ discontinuation of trial Or Two years after granting of the last marketing authorisation in the EU and no pending or contemplated marketing applications in the EC. OR Two years after formal discontinuation of the investigational product. Retain in accordance with applicable legislation and in accordance with the maximum period of time permitted by the hospital or Health Board Retain as long as the product is authorised Five years after the medicinal product is no longer authorised

Medicines for Human Use (Clinical Trials) Amendment Regulations 2006 Governance Arrangements for NHS Research Ethics Committees Should be a flag or divider in health record or Digitised Health Record for documents pertaining to research indicating that the patient has been recruited to a clinical trial or other research. NB Documents can be retained for a longer period if required by the applicable regulatory requirements or by agreement with the sponsor. It is the responsibility of the sponsor to inform the hospital when these documents no longer need to be retained




42

Data collected in the course of Research

Retain for appropriate period to allow further analysis by original or other research teams and support monitoring by regulatory and other authorities

Good Research Practice (MRC Ethics Series, 2000) Data Protection Act, 1998 – Part IV Section 33 (3)


Scanned Records

Paper records that have been scanned in accordance with the Health Boards procedures and QA process

3 months from date of scanning – see note

NB Providing the scanning process and procedures are compliant with BSI BIP:0008 Code of Practice for Legal Admissibility and Evidential Weight of Information Stored Electronically, once the case notes have been scanned the paper records can be destroyed. NOTE: It has been agreed that the paper copies of the record will be retained for eight months (due to storage limitations) post scan until a further audit is conducted and level of assurance provided to the Health Board at which point it will reduce to 3 months

Speech and Language Therapy Records

Retain for the period of time appropriate to the patients/ speciality eg children’s record retained as per retention period for records of children and young people, mentally disordered person (Mental Health Act 1983) 20 years after last entry in record or 8 years after patient’s death, if patient died in care of the HB.

Suicide – notes of patient having committed suicide

10 years

Surgical Appliances

Retain for the period appropriate to the patient/speciality




43


Transplantation Records

Records not otherwise kept or issued to the patient record relating to investigations or storage of specimens relevant to organ transplantation

Retain for 30 years The Retention and Storage of Pathological Records an Archives (3

rd Edition 2005) Addendum 1

Ultrasound Records

e.g. vascular, obstetric Retain for the period of time appropriate to the patients/ speciality eg children’s record retained as per retention period for records of children and young people, mentally disordered person (Mental Health Act 1983) 20 years after last entry in record or 8 years after patient’s death, if patient died in care of the HB

Video records/voice records

Relating to recording of patient care/video records/video-conferencing records relating to patient care/DVD records related to patient care – includes Telemedicine Out of hours records (GP Cover)

8 years subject to the following exceptions or where there is a specific statutory obligation to retain records for longer periods

Children/young people – Records must be kept until the patients 25

th birthday, or if the patient

was 17 at the conclusion of treatment, until their 26

th birthday, or until 8 years

after the patient’s death

Maternity – 25 years

Mentally Disordered persons- 20 years after the date of last contact between patient/client/service user and any healthcare professional or 8 years after death if sooner




44

Video records/voice records (cont)

Cancer Patients- 8 years after conclusion of treatment especially if surgery was involved – Royal College of Radiologists recommend that such records be kept permanently where chemotherapy and/or radiotherapy was given


Vulnerable Adults

Where a patient/client/service user is transferred from the care of one NHS or social care organisation to another, all relevant information must be transferred to the patient’s health or social care record held at the receiving organisation and they should then be retained for the period of time appropriate to the speciality

Where a patient/client/service user is assessed by a health or social care professional including ambulance personnel and is identified as a vulnerable adult the professional should follow the protocols for dealing with vulnerable adults in their organisation.

X-ray Registers Local decisions should be made with regard to the permanent preservation of these records, in conjunction with relevant health professionals and places of deposit

X-ray films – including other image formats for all imaging modalities/diagnostics

General Records Children/Young People Maternity Clinical Trials

8 years after conclusion of treatment Until the patient’s 25

th birthday, of if

the patient was 17 at conclusion of treatment, until their 26

th birthday – or

8 years after the patient’s death if sooner 25 years after the birth of the child including still births 15 years after completion of treatment

X-ray films – including other image formats for all imaging modalities/diagnostics




45

Litigation Mental Health

Records should be reviewed 10 years after the file is closed. Once litigation has been notified (or a formal complaint received) images should be stored until 10 years after the file has been closed 20 years after no further treatment considered necessary or 8 years after death

X-ray Referral/Request cards Providing there is a record in the patient’s health record that a referral/request was made for an x-ray

8 years X-ray Referral/Request cards

Wards Admission/Discharge Books

Admission/Discharge books (i.e. register of those discharged by the hospital)

Permanent Preservation Local decision made to ensure the permanent preservation of these records, in consultation with relevant health professionals and Gwent Archive

Aneurin Bevan University Health Board ABHB/IM&T/0407 Title: Non-Clinical and Clinical Records Retention Schedule

Owner: Head of Health Records


46

4 APPENDIX A

(Appendix B extracted from Health Service Circular WHC (2000)71)

[And B2 - (For the Record: Managing records in NHS Trusts & Health Authorities)] Principles to be used in determining policy regarding the retention and storage of essential maternity records.

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

Joint Position on the Retention of Maternity Records Principles to be used in determining policy regarding the retention and

storage of essential maternity records. 1. All essential maternity records should be retained. 'Essential' maternity

records mean those records relating to the care of a mother and baby during pregnancy, labour and the puerperium.

2. Records that should be retained are those which will, or may, be

necessary for further professional use. 'Professional use' means necessary to the care to be given to the woman during her reproductive life, and/or her baby, or necessary for any investigation that may ensue under the Congenital Disabilities (Civil Liabilities) Act 1976, or any other litigation related to the care of the woman and/or her baby.

3. Local level decision making with administrators on behalf of the health

body must include proper professional representation when agreeing policy about essential maternity records. 'Proper professional' in this context should mean a senior medical practitioner(s) concerned in the direct clinical provision of maternity and neonatal services and a senior practising midwife.

4. Local policy should clearly specify particular records to be retained AND

include detail regarding transfer of records, and needs for the final collation of the records for storage. For example, the necessity for inclusion of community midwifery records.

5. Policy should also determine details of the mechanisms for return and

collation for storage, of those records which are held by mothers themselves, during pregnancy and the puerperium.




47

List of maternity records to be retained Maternity Records retained should include the following:- 1. Documents recording booking data and pre-pregnancy records where

appropriate;

2. Documentation recording subsequent antenatal visits and examinations; 3. Antenatal in-patient records;

4. Clinical test results including ultrasonic scans, alpha-feto protein and chorionic villus sampling;

5. Blood test reports;

6. All intrapartum records to include, initial assessment, partograph and

associated records including cardiotocographs;

7. Drug prescription and administration records;

8. Post-natal records including documents relating to the care of mother and

baby, in both hospital and community settings




48

5 APPENDIX B

Extracted from Annex D3 (For the Record: Managing records in NHS Trusts

& Health Authorities): Electronic Record/Audit Trails

1. Electronic records are supported by audit trails, which record details of all additions, changes, deletions and viewings. Typically, the audit trail will include information on:

Who – identification of the person creating, changing or viewing

the record;

What – details of the data entry or what was viewed;

When – date and time of the data entry or viewing; and

Where – the location where the data entry or viewing occurred.

2. Audit trails are important for medico-legal purposes as they enable the reconstruction of records at a point in time. Without its associated audit trail, there is no reliable way of confirming that an entry is a true record of an event or intervention.

3. NHS Connecting for Health is considering the impact of the retention of

audit trail data eg. whether it should be retained for at least the same period as the data to which it relates. There is also an unresolved issues regarding the association of audit trail data with electronic GP records transferred between practices.

4. Advice and guidance specific to audit trails will be issued in due course on the Department of Health website (http://www.dh.gov.uk/Policyand Guidance/Organisation Policy/Records Management/). In the meantime NHS organisations are advised to retain all audit trails until further notice.

http://www.dh.gov.uk/Policyand%20Guidance/Organisation%20Policy/Records%20Management/

http://www.dh.gov.uk/Policyand%20Guidance/Organisation%20Policy/Records%20Management/



49

Appendix C

ANEURIN BEVAN UNIVERSITY HEALTH BOARD

PHYSICAL HEALTH RECORDS INVENTORY FORM

This inventory concerns records held on physical media including: paper, x-ray film,

microfiche, optical disks, CDs, DVDs, video and audio tape. It excludes records held digitally

within computer systems and centralised network storage systems.

A form is to be completed for each type of record held.

Directorate Location

Department/Service

Contact Name Telephone Number

1. Do you store physical health

records in the Department?

(Records held within the

department on physical

media as listed above).

Yes If Yes, please complete and return the

questionnaire

No If No, you do not need to answer any other

questions, please sign at the end and return the

questionnaire

2. Name/type of record

e.g. OT, DN client

3. Who is responsible for

managing these records

within your dept?

Typically, this person will be

the manager of the dept. or

you may have a records

manager. (Please note: this is

NOT the Health Records

Dept.)

Name:

Job Title:

Tel No:

4. Format of the record Paper Film / X-Ray

Microfilm Other (please

specify below)

Removable

magnetic

media

5. Why are the records created /

held?

Patient care /

patient admin

Legal

Requirement

Clinical Audit Business /

Corporate



50

Research Other (please

specify below)

Central

Returns

6. From where does the

information within the record

originate?

Generated within the Department

Transferred from within the

organisation (ABUHB)

Transferred from an external

organisation (please specify)

7. Does the record contain

personal data / information?

Yes No

If yes, is it

about the

Patient Family

Friends,

Associates

Others

8. Is there a register/index of the

records held?

Yes No

9. How many records of this

type do you hold in your

dept?

10. Where are the records stored?

e.g. cupboard in corridor,

filing cabinet in sister’s

office. (Please list all areas)

11. Is the storage area accessible

to the public?

Yes No

12. Is the storage area secure? Yes No

13. Is access to the record

restricted to within the

directorate/department?

Yes No

14. Is the record or information it

contains shared With others?

Yes No

If yes, with whom is it shared

and why?

(Please list organisations and

depts. e.g. Newport LA

Social Services, Social

Worker. ABUHB District

Nurse

15. Do you have a record

tracking system?

Yes No

If yes, is it

Paper based? Electronic?



51

FURTHER COMMENTS

If you have further comments or questions regarding the information you hold (e.g. creation,

maintenance, storage, retention, disposal etc.) please specify below.

Please return the form to:

Information Governance Unit

Aneurin Bevan University Health Board

B Block, 2nd

Floor

Mamhilad House

Mamhilad Park Estate

Pontypool

NP4 0YP

Tel: 01495 765 5324 e-mail: [email protected]

Completed by:

Date returned:

Non Clinical and Clinical Records Retention Schedule · referred to for the current version of the...

Documents

Transcript of Non Clinical and Clinical Records Retention Schedule · referred to for the current version of the...