DOCUMENT CONTROL PAGE - Bolton NHS FT · 2015-04-01 · Training and Communication Page 13 Actions to be taken if policy is breached Page 14 ... 2.2 This policy does not include copies

DOCUMENT CONTROL PAGE

Title: Records Management

Policy -

Version Number as from December

2004: 5

Document Type: Policy

Scope: Trustwide Classification: Organisational

Authors: Graham Fullarton – Information Governance Manager

Lisa Galligan-Dawson – Access, Booking, Choice, Receptions and Records

Services Manager

Groups Consulted: Health Records Forum, Information Governance

Committee, IT and Information Committee, Governance Committee,

Nominated divisional representatives

Validated By: IM&T Committee Equality Impact Assessed:

Date: 8th

January 2015

(If appropriate) Replaces Description of amendments: .

Authorising Body:

Risk and Assurance

Date of Authorisation : 3

rd March 2015

Master Document Controller: Rebecca Moden

Review

Date:

Key Words: Records Management, Health records, storage, retention, information governance, NHS LA

INDEX

Introduction and Purpose (NHS LA 1.7b) Page 3

Scope and Definitions Page 4

Aims and Objectives Page 5

Roles and Responsibilities (NHS LA 1.7a) Page 5

Practical considerations in managing records Page 7

Guidance on Specific Document Types Page 11

Training and Communication Page 13

Actions to be taken if policy is breached Page 14

Equality Impact Assessment Page 14

Monitoring and Review (NHS LA 1.7g) Page 14

References Page 15

Records Management Policy –

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Appendix A - Summary of Strategic Aims Page 16

Appendix B – Health Records Retrieval Procedures (NHS LA 1.7e)

Page 17

Appendix C - Folders and Documentation

Page 19

Appendix D – Transportation of Records Page 24

Appendix E - Storage of Records Page 27

Appendix F - Tracking of Paper Records (NHS LA 1.7c and d)

Page 31

Appendix G - Health Records Retention Schedules (NHS LA 1.7f)

Page 32

Appendix H – Non-Health/Corporate Records (NHS LA 1.7f)

Page 92

Equality Impact Assessment Proforma Page 131


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1. Introduction and Purpose

1.1 Records Management is the process by which an organisation manages all the aspects of records whether internally or externally generated and in any format or media type, from their creation, all the way through their lifecycle to their eventual disposal. 1.2 The Records Management: NHS Code of Practice has been published by the Department of Health as a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice. 1.3 The Trust’s records are its corporate memory, providing evidence of actions and decisions and representing a vital asset to support daily functions and operations. Records support policy formation and managerial decision-making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways. 1.4 The Trust Board has adopted this records management policy and is committed to ongoing improvement of its records management functions as it believes that it will gain a number of organisational benefits from so doing. These include: • better use of physical and server space; • better use of staff time; • improved control of valuable information resources; • compliance with legislation and standards; and • reduced costs. 1.5 The Trust also believes that its internal management processes will be improved by the greater availability of information that will accrue by the recognition of records management as part of corporate governance. 1.6 This document sets out a framework within which the staff responsible for managing the Trust’s records can develop specific policies and procedures to ensure that records are managed and controlled effectively, and at best value, commensurate with legal, operational and information needs. 1.7 This policy meets the requirements of the Information Governance Toolkit Standard 601, the Care Quality Commission’s Essential Standards of Quality and Safety and the requirements of the NHS Litigation Authority.

1.8. Legal Responsibilities All NHS records are Public Records under the Public Records Acts and must be kept in accordance with the following statutory and NHS guidelines, including email and electronic records:

The Public Records Act 1958 and 1967;

The Data Protection Act 1998;

The Freedom of Information Act 2000;


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The Common Law Duty of Confidentiality;

Records Management: NHS Code of Practice 2006;

The NHS Confidentiality Code of Practice

NHS Litigation Authority Standards

Research Governance Framework and any new legislation affecting records management as it arises.

2. Scope and Definitions

2.1 This policy relates to all clinical and non-clinical operational records held in any format by the Trust. These include: • all administrative records (e.g. human resources (personnel), estates, financial and accounting records, contracts, litigation, records associated with complaints) • all patient health records (for all directorates including private patients, registers, photographs, slides, images including x-ray and imaging reports, audio and video tapes etc.) 2.2 This policy does not include copies of documents created by other organisations such as the Department of Health, kept for reference and information only. 2.3 Records Management is a discipline which utilises an administrative system to direct and control the creation, version control, distribution, filing, retention, storage and disposal of records, in a way that is administratively and legally sound, whilst at the same time serving the operational needs of the Trust and preserving an appropriate historical record. The key components of records management are: • record creation; • quality of records and accessibility; • record keeping standards and record maintenance systems; • disclosure and information sharing; • transfer and tracking of record movements; • storage; • culling/reviewing, closure; • retention; • archiving; • disposal. 2.4 The term Records Life Cycle describes the life of a record from its creation/receipt through the period of its ‘active’ use, then into a period of ‘inactive’ retention (such as closed files which may still be referred to occasionally) and finally either confidential disposal or archival preservation. 2.5 In this policy, Records are defined as ‘a recorded document which forms part of a structured file that contains information, in any medium (including electronic, audio, visual, microfiche), created or received and maintained by the Trust in the transaction of its business or conduct of affairs and kept as evidence of such activity’. 2.6 Information is a corporate asset. The Trust’s records are important sources of


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administrative, evidential and historical information. They are vital to the Trust to support its current and future operations (including meeting the requirements of Freedom of Information legislation and Subject Access requests under the Data protection Act), for the purpose of accountability, and for an awareness and understanding of its history and procedures.

3. Aims and Objectives

3.1 The aims and objectives of our Records Management System are to ensure that:

• records are available when needed - from which the Trust is able to form a reconstruction of activities or events that have taken place;

• records can be accessed - records and the information within them can be located and displayed in a way consistent with its initial use, and that the current version is identified where multiple versions exist;

• records can be interpreted - the context of the record can be interpreted: who created or added to the record and when, during which business process, and how the record is related to other records;

• records can be trusted – the record reliably represents the information that was actually used in, or created by, the business process, and its integrity and authenticity can be demonstrated;

• records can be maintained through time – the qualities of availability, accessibility, interpretation and trustworthiness can be maintained for as long as the record is needed, perhaps permanently, despite changes of format;

• records are secure - from unauthorised or inadvertent alteration or erasure, that access and disclosure are properly controlled and audit trails will track all use and changes. To ensure that records are held in a robust format which remains readable for as long as records are required;

• records are retained and disposed of appropriately - using consistent and documented retention and disposal procedures, which include provision for appraisal and the permanent preservation of records with archival value; and

• staff are trained - so that all staff are made aware of their responsibilities for record-keeping and record management.

4. Roles and Responsibilities

4.1 The Trust has a legal responsibility to ensure that all its clinical and administrative staff keep proper records. 4.2 The Trust has a statutory duty to make arrangements for the safe-keeping and eventual disposal of its records. This is carried out under the overall guidance and supervision of the keeper of public records.


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4.3 All NHS records are public records under the terms of the Public Records Act 1958. Public records over thirty years old and selected for permanent preservation must be transferred to the Public Record Office or kept in a place of deposit, appointed under the Public Record Act 1958.

4.4 All Trust staff, whether clinical or administrative, are responsible for any records they create, receive and use and are responsible for adhering to the Trust’s policies and procedures in relation to records management. In particular all staff must ensure that they keep appropriate records of their work in the Trust and manage those records in keeping with this policy and with any guidance subsequently produced.

4.5 The Chief Executive has overall responsibility for records management in the Trust. As accountable officer he/she is responsible for the management of the organisation and for ensuring appropriate mechanisms are in place to support service delivery and continuity. Records management is key to this as it will ensure appropriate, accurate information is available as required. The Trust has a particular responsibility for ensuring that it corporately meets its legal responsibilities, and for the adoption of internal and external governance requirements.

4.6 Divisional Directors of Operations, Heads of Divisions and General Managers are responsible for ensuring that records held within their areas of responsibility fully comply with the policies and procedures set by the Chief Executive. They are also responsible for ensuring staff, whether administrative or clinical, are adequately trained and apply the appropriate procedures.

4.7 Managers are responsible for ensuring that staff under their direction and control are aware of the policies and procedures and guidance laid down by the Chief Executive and for checking that those staff understand and appropriately apply the policies in carrying out their day to day work. They should be aware of the types of records that are being created, who is responsible for the maintenance of these and to maintain a list of compliant storage locations (see para 4). They are also responsible for deciding whether a record is closed, archived, disposed of or permanently preserved. Decisions regarding disposal or permanent preservations should be made in conjunction with the Information Governance Manager, and where patient Health records are concerned, the Trust’s Health Records Manager

4.8 The Trust’s Caldicott Guardian has a particular responsibility for reflecting patients’ interests regarding the use of patient identifiable information. They are responsible for ensuring patient identifiable information is shared in an appropriate and secure manner.

4.9 The Lead for Freedom of Information (FOI) is responsible for administering all requests for information made to the Trust. The Lead for FOI will also provide a point of contact for all members of staff who require advice on freedom of information act matters. The lead for FOI will, where possible, provide advice directly to staff on FOI Act matters or otherwise refer to a competent person to obtain such advice.

4.10 The Trust’s Information Governance Manager/Information Governance

Committee is


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responsible for ensuring that this policy is implemented, through the Records Management Strategy, and that the records management system and processes are developed, co-ordinated and monitored. A summary of strategic aims relating to Record Keeping Standards can be found in Appendix A

4.11 The Health Records Manager is responsible for the overall development and maintenance of health records management practices throughout the Trust, in particular for drawing up guidance for good records management practice and promoting compliance with this policy in such a way as to ensure the easy, appropriate and timely retrieval of patient information. 4.12 The responsibility for local records management is devolved to the relevant directors, Divisional Directors of Operations,, Heads of Divisionss and their teams via Information Asset Owners.

5. Practical considerations in managing records 5.1 Quality of records including accessibility 5.1.1 Records are valuable because of the information they contain. To ensure quality and continuity of operational services, information is only usable if it is accurate, correctly and legibly recorded in the first place, kept up to date and easily accessible when needed. 5.1.2 To comply with Data Protection principles, records should not be kept for longer than is necessary and therefore should be subject to review and archive or deletion at the expiry of their retention period. 5.1.3 Hard copy records must be bound and stored to prevent loss within files which are robust and clearly labelled. Where Health Records are concerned, patient identifiable details should not be visible on the outside of any case note. 5.2 Storage of records, including security and confidential conditions of physical files 5.2.1 Hard copies of records must be kept secure and should be stored in an appropriate filing cabinet, office or designated records store so they are available and accessible to those who need them. Information retained must be in line with national guidance, the Data Protection Act 1998, the NHS Code of Practice on Records Management, the NHS Code of Practice on Confidentiality, the Criminal Records Bureau Code of Practice and ISO/IEC 27002 for Information Security. 5.2.2 It is the responsibility of all staff to ensure security and confidentiality of records in their possession and to be aware of ways in which these responsibilities may be contravened. 5.2.3 The storage of all physical records must be in accordance with Health and Safety requirements and legislation.

5.3 Creation of a Health Record


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The NHS number acts as the primary national identifier on LE2.2 for the patient. However, every patient who attends the Hospital for the first time is registered with a unique identification number this is generated via the Hospital Patient Administration System (LE2.2) by either the member of staff creating a referral based outpatient episode in the appointment centre, by the Emergency Department as part of the admission process, GP Direct or the wards depending on how the patient comes in to the Trust All Patient Health Records are bar code labelled with the NHS number, Hospital Medical Record Number

Elective Outpatients Following on from Registration the Outpatient appointment is made, which in turn starts to create a clinic schedule. Medical Records (or appropriate satellite department) will generate from LE2.2 a pull list per clinic. This identifies the whereabouts of the notes including identification of new patients. New patients will receive a brand new Case note folder created at the clinic administration stage by Medical Records staff (or appropriate satellite department). This folder will be dispatched to the outpatient clinic and used for all subsequent episodes by the appropriate clinical staff.

Emergency Attendance / Emergency Admission When a patient is admitted to the Hospital their personal identification details are either updated or registered at the point of admission (e.g. Emergency Department). At the point of admission Medical Records will receive a request over the phone/ bleep or directly in to the department via a designated print request process for the notes to be dispatched to the appropriate Ward. If the patient has not been seen in the Hospital before a new Case note folder will be allocated to that patient by the Medical Records staff. Bolton NHS Foundation Trust operates a 24 hour records service.

5.4 Transfer and Tracking of Paper Records: 5.3.1 It is a requirement of the Trust that the owner of the record knows the whereabouts of a specific file at all times, regardless of the type of record. In terms of Health Records that are missing, these pose significant risks to clinical care and loss of income due to the inability to code episodes of care and thereby affecting payment by results.

5.4.2 Health Record Casenotes Tracking. The Casenotes tracking system provides access to a range of features for tracking hospital Casenotes and recording the current location. The procedure for tracking casenotes is referenced in appendix F. 5.4.3 It is the responsibility of all Trust staff to ensure the Patient Administration System is updated with the appropriate Health Record casenote tracking code, ensuring specific details are entered in the free text comment field re specific location of record)


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5.4.4 Health Record Casenote tracking must be completed at all times when a set of

patient’s casenotes are leaving the department or ward to go to another. It is essential

for patient care that the correct casenotes can be located at all times. 5.4.5 Security of ALL records is paramount, particularly those containing personal identifiable data and staff must therefore take the appropriate level of care when records are being transferred within the Trust or sent outside the Trust. See appendix D 5.5 Further guidance on the transporting of personal identifiable information (by phone, fax, in person, by email and by post or other methods) is contained in the Trust’s Information Security Policy.

5.6 Culling of Closed Volumes 5.6.1 The Trust will ensure that closed volumes of ALL records are culled on a regular basis (at least annually) to ensure only active records remain on file and inactive documents are either archived (in line with the Retention Schedule) or confidentially destroyed (by shredding or incineration). It is the responsibility of the head of each division or directorate to ensure local procedures are in place. For the purpose of Health records. Archived or inactive records are those records which have not been used for a period of 3 years.

5.7 Retention 5.7.1 It is a fundamental requirement that ALL of the Trust’s records are retained for a minimum period of time for legal, operational, research and safety reasons. The length of time for retaining records will depend on the type of record and its importance to the Trust’s business functions. 5.7.2 The length of the retention period depends upon the type of record and its importance to the business of the Trust. The destruction of records is an irreversible act, whilst the cost of keeping them can be high and continuing. 5.7.3 The Trust has adopted the retention periods for paper and electronic records set out in the Records Management: NHS Code of Practice (Appendices C and D). The Trust has local discretion to keep material for longer subject to local needs, affordability and where records contain personal information, the Data Protection Act 1998. The retention schedule will be reviewed in line with this policy reviewe date.. It is the responsibility of each Director to ensure documents are maintained in accordance with this schedule. Local guidelines should be in place for each directorate for the retention periods of local records, e.g. departmental message books. 5.7.4 If a particular record is not listed within the Retention, Review and Disposal Schedule, advice should be sought from the Information Governance Manager who will establish the retention period in consultation with the department concerned.


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5.7.5 Permanent Retention Health Records can be retained permanently (not destroyed in line with the Trust destruction policy), where there is a legitimate reason. Reasons for permanently retaining records include: Genetic / hereditary conditions Research Unusual / complex illnesses Treatment of a relative with complex / unusual illnesses Litigation This list is not exhaustive. Permanent retention can be requested by any treating clinician or research lead. The reason for permanent retention must be clearly visible on the case notes, and written in the electronic tracking system for this record. All case notes which are required for permanent retention are to be clearly identifiable with royal blue tape placed around all the edges of the case notes. It is accepted that Green tape has previously been used within the community setting up to 2012. All notes containing green tape must be permanently retained. Blue tape is to be used in all cases as from June 2012. Requests for permanent retention should be made to both the Health Records Manager and the Information Governance Manager

5.8 Archiving 5.8.1 Any files and information which cannot be maintained on Trust premises, may be stored off-site in commercial storage subject to appropriate scrutiny probably including a business case Archiving refers to files which are inactive. In terms of Health records this is defined as records not used for 3 years. 5.8.2 Archived files must be clearly and appropriately indexed and labelled. All archived records must have a clear destruction date (for Health Records the date of destruction may subsequently alter should the patient have additional episodes or attendance with the Trust. A manual check against the Trust PAS system will be required before any Health Record can be destroyed). 5.8.2 Any files and information which cannot be maintained on Trust premises, may be stored off-site in commercial storage subject to appropriate scrutiny probably including a business case. Any Health Records which are not frequently used but do not meet the defined archive definition remain the responsibility of the creating department for devolved records and Medical Records department for hospital case notes.


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5.8.3 Any archived record required to be use for information purposes must NOT be written in. Archived records are for information only, and any new information should only be recorded in the most recent live version.

5.9 Disposals and Destruction 5.9.1 A number of copies of the same document may be stored by recipients of that document, for example meeting papers. It is incumbent upon the person who has lead responsibility for the retention of that record (shown in the column of the Retention Schedule) to retain the document for the requisite period and then to arrange for its disposal. Retaining records longer than is necessary is against the Data Protection Act and therefore is actively discouraged. 5.9.2 It is important that staff select the method of disposal in accordance with the type of record or data to be destroyed. Personal identifiable data must be confidentially destroyed by shredding or similar using an approved Trust supplier. Even many administrative records containsensitive or confidential information. It is therefore vital that confidentiality is safeguarded at every stage and that the method used to destroy such records is fully effective and secures complete illegibility. 5.9.3 Disposal is the responsibility of the individual department or the record keeper. Records must be destroyed as confidential waste as per the Trust’s Waste Management Policy .

6. Guidance on Specific Document Types 6.1 Agendas, Minutes of Meetings and Associated Papers 6.1.1 Only the Chair of the meeting is required to retain the meeting papers in accordance with the Trust’s Retention Schedule. Other members who attend the meetings may keep their copies of papers at their own discretion. 6.1.2 Trust Board meeting minutes are signed and kept as a hard copy.

6.2 Records relating to Estates 6.2.1 Estates records are retained for at least the minimum periods in accordance with the Code of Practice as set down in the Retention Schedule although in some instances for sound business reasons they may be kept for longer. The only exception to the Code of Practice relates to the retention of property documents and plans which requires Trusts to maintain these for the 'lifetime of the organisation'. Thus they would tend to keep these records ‘for the lifetime of the site and/or building to which they relate’ and occasionally for a certain length of time afterwards.

6.3 Emails 6.3.1. It is important that email messages are managed in order to comply with the Data Protection and Freedom of Information legislation. Staff need to be able to identify which emails (sent and received) are records of business activity and/or a formal record of a


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transaction (and therefore which need to be captured as records and saved/located with other records relating to the same business activity) and which are ephemeral messages (which only need to be kept for as long as required and then deleted). 6.3.2 Mailboxes should not be used for long-term storage of email messages. Personal mailboxes should be used for short-term reference only and when these emails are no longer required they should be saved on the relevant server or deleted. 6.3.3 Any emails sent and received from a Trust email account form Corporate Records, and as such are subject to this policy. The sending of Electronic (and Fax) records (data) will be governed by the Information Security Policy.

6.4 Policies and Procedures 6.4.1 The Trust’s Clinical, Non-Clinical, Human Resources, Finance, Information Governance and Directorate Specific Policies are available from the website and word versions of them are maintained electronically in relevant folders managed by the Master Document Controllers. Their process for development, review and dissemination is documented under the Trust’s document control policy.

6.5. Personal Files

6.5.1 Recruitment and Employment On preparation of an offer of employment a Recruitment Personal File is established by the Recruitment Department which contains the application form and associated documents, the offer of employment and documents linked with the employment process. Once the applicant has commenced employment and all the pre-employment checks are complete the Recruitment Personal file is forwarded to the recruiting manager, to be combined with the paperwork held at the place of work to form the Personal File for the employee. Items which may be retained in the Personal File are detailed on the checklist which should be kept in the file for audit purposes. The files should be kept in a secure and lockable cabinet and access restricted to the appropriate personnel. In the case that the employee transfers within the Trust the file should be forwarded to the new manager in a sealed envelope, where services are on the same site, records should always be hand delivered All Personal Files must be held securely by the manager responsible for the file at the time they have ownership of it.

6.5.2 Termination of employment On termination of employment the manager should complete the termination form for the employee, keep one copy in the Personal File and forward the remaining copies


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to HR by the date that employment cease. HR will terminate the employment on ESR ensuring that all outstanding payments are made. The manager should also complete the Termination Formnd place it in the Personal File

6.5.3 Retention of Personal Records The file will be kept for the appropriate period (for 6 years, see NCP 29.2 Retention of Documents Schedule) and will be destroyed at the end of this period. The employment summary document will be retained in Trust for the appropriate period (70th birthday of the employee)

6.6. Finance Records 6.6.1 The Trust’s Finance Directorate will have responsibility for retaining all prime finance documents on behalf of the organisation, with the exception of any financial reports, (including the Trust’s annual accounts), which are received by the Trust Board, where responsibility will lie with the Trust Secretary. Therefore whilst operational managers may retain copies of budget statements for their own particular area, a master copy in compliance with the retention policy will be retained by the finance department. Any copy retained by the manager must be disposed off in line with the retention policy. 6.6.2 Where local arrangements are in place for original receipts in support of petty cash reimbursement or cash receipts which require these records to be retained locally rather than within the finance department, then these must also be retained as per the policy by the department, rather than by Finance.

6.7. Directorate Records

6.7.1 Functional Directors/Divisional Director of Operations are responsible for establishing and maintaining mechanisms through which their departments can register the records they are maintaining. This may be via an inventory for hard copy files and by setting up folders on shared drives for electronic documents. 6.7.2 It is the responsibility of the Functional Directors/divisional managers to review these mechanisms regularly and ensure that the components of this Records Management Policy and the associated Records Management System are adopted and complied with.

7. Training and Communication 7.1 In order to meet the requirements of legislation, national directives, the Trust’s strategy and this policy, it is essential that everyone working in the Trust is familiar with its legal obligations and its internal policy and procedures. The Trust will ensure all staff are aware of their responsibilities for record-keeping and record management through generic and specific training programmes and guidance to ensure they can Competently carry out these responsibilities. An e-learning module will be developed to support this aim.


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Communication will be achieved via Team Briefs, Intranet publication and departmental briefings.

8. Actions to be taken if policy is breached 8.1 Failure to comply with this policy may result in ineffective working and an inability to meet the requirements of the Freedom of Information Act and Data Protection (Subject Access). As an organisation breaches of these policies may be considered reportable to the Information Commissioning Officer (ICO) where fines of up to £500000.00 are admissible Where the policy is breached, managers will consider appropriate action which may include training and education or recourse to the Trust’s Workforce and Organisational policies.

9. Equality Impact Assessment 9.1 This policy has been screened to determine equality relevance for the following equality groups: race, gender, age, sexual orientation and religious groups. This policy is considered to have no equality impact.

10. Monitoring Compliance and Review

Minimum

requirement

to be

monitored

Process for

monitoring

e.g. audit

Responsible

individual/

group/

committee

Frequency

of

monitoring

Responsible

individual/

group/

committee for

review of

results

Responsible

individual/

group/

committee for

development

of action plan

Responsible

individual/ group/

committee for

monitoring of

action plan

Storage and Retention

Audit and Inventory

Information Governance

Annually IM&T Committee

Information Governance

Senior Information Risk Officer

Tracking Audit Health Records

Quarterly Divsional Quality Boards

Health Records

Divsional Quality Boards

10.1 This policy will be monitored by the Senior Information Risk Officer. Sample audits will be undertaken annually and reported to the Information Governance group. It will also be monitored by the Information Governance Manager when investigating claims, FOI requests and requests for historic documents (e.g. duty rotas, personal files etc). 10.2 Methods of monitoring will be reviewed every two years (or sooner if new legislation, codes of practice or national standards are to be introduced).


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11. References

1. NHS Code of Practice – Records Management January 2009 http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Recordsmanagement/index.htm 2. Bolton NHS FoundationTrust Policies: Data Protection Act 1998

Freedom of Information Act 2000 Information Security

3.Essential Standards of Quality and Safety http://www.cqc.org.uk/standards 4. NHS Litigation Authority – Risk Management Standards for Acute Trusts 2012-13 http://www.nhsla.com/RiskManagement/ 5. Enquiries and Tracking Manual http://intranet.rbh.nhs.uk//clientfiles/201241714348_Enquiries%20and%20Tracking.pdf

http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Recordsmanagement/index.htm

http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Recordsmanagement/index.htm

http://www.cqc.org.uk/standards

http://www.nhsla.com/RiskManagement/

http://intranet.rbh.nhs.uk/clientfiles/201241714348_Enquiries%20and%20Tracking.pdf


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Appendix A Summary of Strategic Aims

1. Record Keeping

Development and Training in Record Keeping (electronic and manual) will be given a priority in Records Management.

2. Sharing Records All staff will work towards rationalising record collections through sharing records and the information they contain, (subject to the requirements of the Data Protection Act 1998 and the Principles of Caldicott), by merging or ensuring effective cross-reference. It must be recognised that data belongs to the Trust and not to individuals or departments.

3. Tracking and Security

Security and Tracking of records will be incorporated within the management of all records within the Trust.

4. Storage and Retention of Manual Records

All manual and electronic records, in the Trust will be appropriately stored and retained in accordance with the Bolton Hospitals NHS Trust recommended retention period as agreed by the Members of the Trust Board* and in line with the Department of Health’s Code of Record Management April 2006

5. Non Paper Records The principles of good record management will also apply to electronic data.

6. Disposing of Records

Records will be reviewed under the criteria of the Bolton Hospitals NHS Trust retention periods [Appendix C] and those no longer required by the services of the Trust will be considered for permanent preservation, research, disposal or any other use as agreed by the Trust Board

7. Documentation

Standards will be introduced and applied to the production of Trust documentation (manual and electronic).


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APPENDIX B _ Health Records Procedure

1 Retrieving Records

1.1 Records required for outpatient clinic attendance Clinic lists will be printed three? working days in advance of the clinic date. An updated list will be printed the day before the clinic. Staff booking any additions less than three days before the clinic must report this to the Health Records Department.

1.2 The Health Records staff will deliver records for outpatient clinics to the clinic venue by the start of the clinics session unless a different arrangement has been agreed with the service. The day before the clinic a final check of all records for the following day will be undertaken and a list compiled of any records still outstanding. This list will form the figures for the outpatient monitoring. Health Records are retrieved and prepared for outpatient clinics in accordance the standard work processes (see page ????)

The clinic team will aim to provide as a minimum 99.5% of all records requested

1.3 Records required for elective admission The Health Records Department will retrieve records for elective admissions by request. Any additions to the list less than three days before the admission date will be notified to the Health Department by the Elective Access Team. Records will be delivered to the ward on the day before the admission, unless the patient is attending other appointment's etc.

Where a patient is deemed to have risks during surgery, they will be referred for Anaesthetic review as part of the Trusts Pre-Operative Assessment Policy. For all patients attending the designated Anaesthetics pre-operative assessment clinic, all live and archived case notes will be provided by the Medical Records team. It is the responsibility of Anaesthetics and each specialty to advise Medical Records of any patients subject to this assessment who are attending a clinic other than the designated pre-anaes clinic session, to alert then that archived notes will be required. (see appendix F for management of these records)

1.4 Records required for emergency admissions / emergency attendance. All requests for emergency admissions / attendance will be requested via telephone or bleep on the emergency numbers provided or by direct electronic request. The Health Records Department will respond immediately. The Health Records Department aims to provide records for emergency admissions within 30 minutes of notification

1.5 Miscellaneous requests All other requests will be via the designated telephone number electronic notes procedure and will be dealt with in the timeframe set out according to the nature of request and priority status

1.6 Records required for National audits or research Records required for National audit or research purposes will be requested through the Clinical Audit Department and will require an audit/research number. Any additional audits for departments will need to be arranged via health Records, and will require resourcing by the department


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1.7 Obtaining records out of hours The Health Records Library will be staffed on a 24 hour basis; 365 days per year.

1.8 Any case notes which cannot be provided at the time of a patient attendance or

admittance will continue to be searched for by the Medical Records team (or appropriate satellite area). Records located after the attendance will be delivered to the secretary for correspondence to be added. Any case note requested for filing (by ward or secretary) that has already been provided for the attendance will be chargeable.

1.9 Case notes used for inpatient / day case attendance should be available for

Coding within 24 hours. Case notes will be collected 24 hours after the patient has been discharged for the episode to be coded. It is the responsibility of all ward areas to ensure that the case ntoes are available and contain the full patient episode.

Retrieval / Provision of Archived Notes CD stored, Microfiche and records stored in off site storage facilities can be retrieved for any clinician for any inpatient or outpatient attendance upon request. All requests are via Medical Records department on ………………. (generic email) where records can be retrieved routinely in 24 hours to 7 days dependent on the request and its urgency. In the event of an urgent request – notes can be retrieved or reproduced for patients attending as an emergency by contacting the Medical Records team on the emergency numbers / bleeps.


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Appendix C

FOLDERS & FILING OF DOCUMENTATION

The Health Records Folder - Ensuring Records are Complete and Fit for Purpose

It is essential that a patient record should be complete and fit for purpose at all times. Everyone who uses the records are responsible for this. Fit for Purpose For a record to be fit for purpose it should be bound, with a cover which can clearly contain the patients name and local identifier or NHS number. No other personal details should be visible on the outside of a record (I.e. Date or birth, address, type of treatment they are receiving). The record should also contain a current year label. The folders used for all records should be Trust approved. All items within the records should be bound securely at two points. There should be no loose items within the case notes at all. Where a cover becomes worn and in need of repair, this can be done by the individual in possession of the record. Where the record needs to be re-bound, this record should be returned to Medical Records. When a record becomes full, an additional volume should be created. All personnel should report new volumes required to Medical Records. The Medical Records team will create this record on the system and produce a new folder. The requester will then be required to collect this and use this in conjunction with the original volume. Filing All secretarial teams and wards are responsible for their own filing. All items to be filed should be placed in the appropriate section of the case notes, and be secured at two points. It is not acceptable for any items to be placed loose inside the records. Where possible loose items should not be clipped to the front of case notes. Filing should be completed in a timely manner at all times to ensure that the patient record is kept up to date and complete. Where a Health Record is required for use and is found to have unfiled items with the notes. (i.e. letter or results clipped to the front). These will be removed and left, with a note to say the records have been taken for clinic / inpatient use. The team taking the case notes will be required to add a note on to return on the front of the notes so that they are returned once the episode is complete.


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Care and attention should be taken to also ensure that any items being filed belong to the patient. If items being enclosed deliberately belong to a third party (for care purposes) an explanation as to why these items are included should be available. Results which are available on other Trust systems. I.e blood results on ICM no longer need to be filed in paper records. Results from investigations completed at other Trusts or those not accessible on Trust systems must still form part of the paper record. Where a patient is receiving care as an inpatient or outpatient, it is essential that the information relating to this care record is included in a timely manner. Where the patient record is not available at the time of the episode, the Medical Records department should endeavour to provide the case notes to the secretary / ward for all correspondence to be filed appropriately. If the records are not provided in a timely manner, the secretary / ward must make requests for these notes through Medical Records. It is the responsibility of all secretarial / ward teams to ensure their correspondence is filed within the case notes. Where items need filing, which is not directly linked to a care episode where the notes would have been provided by Medical Records, each team will be responsible for the cost of these notes being retrieved for the purpose of filing via Medical Records. Orderly medical records are a vital part of good medical practice. Difficulty finding information within a disorganised file leads to a lengthening of the duration of consultations, inefficiency in the work of clerical staff and secretaries, the risk of diagnoses being overlooked and the need for investigations to be unnecessarily duplicated. Comprehensive and accessible records are also imperative if complaints or litigation are to be dealt with successfully. The folder design used at the Trust represents the results of consultation with a variety of clinicians and a wide range of users of health records within the Trust. The design reflects best practice elsewhere in the NHS and address the specific requirement of accreditation bodies, most notably the NHS Litigation Authority.

Use of old type records at Bolton NHS Foundation Trust. It is necessary to continue to use existing old format records alongside records of the newer type for a considerable time until they become non-current.

Structured Document Filing In order to meet the specific NHS LA Risk Management Standards, folders do not have a back filing pocket to minimise the risk of misfiling or lost documents. This requires all standard stationery documents used within the Trust to be filed with two holes drilled. All staff are required to use the structured document filing systems established at the Trust and to file all documents onto the spines within the folder. Documents are stored in a logical indexed order behind named dividers to make them easily accessible.


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When new records or new volumes are created the set standard should always be adhered to. The record or new volume must be created on the PAS and as a paper record. The paper record must contain 3 patient bar code labels on the front, 2 on the reverse and a year label at the opening edge of the folder. All volume numbers are identifiable from the bar code labels. All hospital notes are prefixed in the same way. The volume number, followed by HN (to determine hospital note) followed by the patient local identifier (beginning with RMC). i.e. 01/HN/RMC01234567 – indicates volume 1 02/HN/RMC01234567 – indicates volume 2 The standard set of health record dividers must be used which separate information in sections for: History: GP and Consultant Referral Letters

History Sheets Operation Sheets

Correspondence: All copy letters written by hospital medical staff Typed discharge summaries Letters from other hospitals Copies of referral letters between consultants Imaging Reports: X- Ray reports Scan Reports ECG Reports Other diagnostic reports excluding pathology Pathology Miscellaneous: Consent forms Drug/Prescription charts Nursing Care plans Patient questionnaires Monitoring Charts Fluid Balance Blood pressure Temperature Letters from patients All other miscellaneous documents and forms Items from other treating organisations that are clinically required to be retained as part of the records should be filed under miscellaneous.

Case note preparation – Standard Casenotes being prepared for outpatient clinic use will be prepared in accordance with the following standards for all specialities


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Front sheet Half sheet of patient labels as a minimum 1 history sheet, containing patient label and specialty label Referral letter for new attendances Clinical outcome sheets, or specialty specific documents must be produced / managed in clinic by the requesting specialty unless agreed otherwise.

Temporary Folders

Where there is a requirement for filing records on a temporary basis ( on the wards in particular) provision must be made to ensure that these are kept securely and have an index referenced to the patient.

On discharging the patient from the ward ( at the very latest) these records must be filed in the main hospital notes before the casenotes leave the ward.

Health Records – other than main Hospital case notes A&E Where separate records are created in A&E these must be integrated in to the main case notes if the patient is to be treated as an inpatient. For patients who are not admitted are to be stored / retained separately in line with standards within this policy. Specialty / Service Health Records Where speciality / service notes are used separately to the main hospital case notes these should be created, stored and managed in line with the standards outlined in this policy. Management remains the responsibility of the specialty / service, but in consultation with Information Governance and Health Records Management.

Clinical Trials The Trust is required to keep the health records of all patients involved in clinical trials in accordance with the statutory requirement of the EU Directive 2001/20/EC. The Directive states that all clinical trials must be conducted according to Good Clinical Practice (GCP) guidelines. GCP states that all source data, including hospital records, must be retained for 2 years beyond any marketing authorisation, which in practice is a minimum of 15 years. It is the responsibility of the lead investigator conducting the clinical trial to ensure that the health records of patients involved in such trials are clearly marked to ensure that the health records are retained for the appropriate period of time. Records relating to trails will be filed in the research section of the casenotes. This will apply from June 2012.

Staff Responsibilities The success of a quality case note depends on all members of the healthcare team accepting their responsibility of filing of documentation. All staff who handle the case note folder and not just the medical records staff are responsible for maintaining it in a good


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condition and ensuring that investigations and results are filed in accordance with this policy before it leaves their care. Staff must ensure that all filing is complete before forwarding the record to a new location. There should be no loose documentation of any description inserted into the medical record. If staff recognise a problem with the filing of a medical record, then he/she has the responsibility to ensure that it is resolved. All areas using health records are responsible for supplying and using stationery, including health record front-sheets and ID labels appropriately in order to facilitate good record keeping practices. Individual documents must never be removed from the health records folder or separated from a records entirety.


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Appendix D

Transportation of Records Transportation covers ALL types of Records. Care must be taken with the transportation of all records to ensure the integrity of the record is maintained and that all documents are kept safely in line with the standards in the Records Management policy.

For all record types (except Health Records) Where possible the use of external post should be avoided. Any confidential records must be sealed with tape in a new and robust envelope clearly addressed, marked ‘Private & Confidential – Addressee only’ and stamped with ‘Internal Mail’. The sender’s name and address should be marked on the back of the envelope. When necessary, (e.g. with a large file) always use a second envelope to reduce the risk of the contents escaping or being damaged. Always ask the recipient to confirm receipt.

Transportation of Health Records The transportation of Health Records includes the movement of records between one department and another, working in multiple locations, sending records to patients or other organisations and mobile working. All employees of the Bolton NHS Foundation Trust are bound by the Publicised Codes of Practice and have a duty of care towards the safe transportation of all records. Internal transportation Where records are transferred within the same site (between departments) care should be taken to ensure that the records are transported securely and that all patient / staff identifiable data is kept confidential. Where there is identifiable data contained in records, these items should not be transported in the internal mailing system. All records should be delivered or collected by a responsible person. Where items are being transferred by a responsible person, envelopes used should be marked strictly private and confidential. Where envelopes are not being used, a secure box or container should be used. All users are responsible for the secure and appropriate transportation of all records. All reasonable care and attention should be made to ensure that records are not left in unattended areas, or kept in areas with full public access. Where patients attend an outpatient clinic from a ward, or where patients attend a second appointment on the same day, patient records should be transported by hospital personnel only. Patients or their relatives should not transport their own records. Wards and departments are to agree local arrangements. External Transportation / Postal Services


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All records are to be transported by Trust transport services or by a Trust approved courier or taxi service (details of approved suppliers are available from Transport department / Site Services) When working with other NHS organisations, an NHS approved courier or their own transport service can also be used, as they are governed by the same standards. However, if work is taking place with a private organisation (i.e. a private hospital) governance arrangements are not the same, and the Trust transport / Trust approved supplier rules apply. All records should be transported in a fit for purpose lockable box or secure tamper proof envelope. The Royal Mail postal system should not be used for transporting any Health records between trust sites, nor should personal vehicles belonging to Trust employees The Royal Mail postal service should only be used for permitted postal items, and the post should only be used when no other options are available or when the patient / recipient has specifically requested this I.e. copies of records requested by patients. When the

post is used, all items MUST be sent using special delivery. Mobile Working Staff members who are mobile (district nurses etc) should ensure that all reasonable precautions are taken when transporting records whilst on duty. Items being used throughout the day should be stored in a lockable container. Items should be removed from vehicles at the end of the working day and returned to a Trust property for safe storage where practicable. Items should not be left in vehicles overnight. Responsibility for the secure storage of the records rests with the member of staff. All items should be removed from vehicles at the earliest opportunity (each day minimum). Use of Health Records in alternative settings When records are being used for Trust purposes. I.e. outpatient clinics being held at a location other than where the record is kept, is it expected that the original Health Record should always be sent (following transport procedures within this policy.). This includes continuous care within the Trust (patients stepped down from hospital to intermediate care) When a health Records are requested by another external party copies of case notes should be used at all times, with the original retained on site unless an emergency situation presents itself and where there is a risk to life. Reasons why we may be asked to provide the original Health Records include: Case Hearing Coroners’ Office Solicitor Use – Via Trust Litigation On-going emergency care at another hospital


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In all cases where the original Health Record to be used in their original format outside of their designated storage base they must be tracked accurately and in a timely manner. There are no exceptions to this rule. (See tracking section).

Where any original notes are being taken off site, 24 hour access is required. There

are no exceptions to this rule. Any individual sending health records off site must

ensure contact details for 24 hour access are included in the comments section of

the tracking section The sending of Electronic (and Fax) records (data) will be governed by the Information Security Policy.


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Appendix E

Storage of Records

The storage of records is a critical part of ensuring compliance with Data Protection and Governance. This section applies to live and archived records of ALL types All records should be stored securely with the appropriate restrictions to access depending on the nature of the record and its use. The use of any records containing personal identifiable data is not permitted in properties which do not belong to the NHS unless written protocol is agreed. Storage accommodation for ALL records must be clean and tidy in order to prevent damage to records. Storage of live Health Records Within both hospital and community settings case notes must be stored in designated storage facilities. All case notes should be returned at the earliest opportunity to the main Records store for the site. (For RBH this is the main Medical Records Library). With live records, it is understood that during care episodes the records will need to be retained by other departments/sites. Each department and site will be responsible for ensuring there is adequate security for all health records in their care. All care records should be returned, complete to the main storage location as soon as

possible. All notes must be tracked at all times (see appendix F). Where a designated notes storage area is not available, a records trolley or secure filing cabinet can be used within an access controlled environment not directly accessible to the public. There is to be 24 hour access to all case notes, and therefore accurate tracking and storage is essential. Where temporary storage is in place. I.e. IMC, each unit should keep their own records of records received and returned for audit purposes. Mobile use of notes. Where notes are required to be carried in a vehicle over a designated shift period, items should be stored in a lockable box. Items should be returned to their designated storage location at the earliest possible opportunity. Health Records should not be stored in private cars or premises overnight in any circumstances. Security of Health Records It is essential the records are stored safely at all times.


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Records should not be stored in any location which would be unmanned and directly accessible to the public. Storage areas should be accessible via door coded entrances / swipe access. Storage locations must be fit for purpose, labelled and each area easily identifiable to others. Storage of Archived Health Records (or live records stored in offsite storage locations) Only Trust approved private (off site) storage locations may be used. (Contact Health Records Manager / Information Governance Manager for details). All offsite storage locations will have formal agreements drawn up for the safe storage of all records placed in their care. All records stored off site need to be stored in conjunction with these agreements. All boxes sent to offsite storage should contain an inventory list (A list of everything in the box and their retention periods). All boxes are to be sent in a fit for purpose state and be clearly labelled in conjunction with the standards written in the formal agreement. For any department using offsite storage accurate record keeping is essential. It is a requirement to keep a log of everything sent off site for storage. It is not acceptable to keep a list of box numbers sent for storage. Each department / site using offsite storage are required to keep a full catalogue record of all items sent off site for storage. There should be a record of all box numbers belonging to the department, as well as a full list of all items contained within those boxes. Including NHS / local identifier numbers, names, type of record, retention period. All records should be kept electronically on a system which is supported by back up to retain these records. All records should be able to be reproduced for audit requirements. Additionally, each department / site should retain a record of all items stored off site which have been retrieved out of storage. Use of live Health Records in other locations The use of any Health Records containing personal identifiable data is not permitted in properties which do not belong to the NHS unless written protocol is agreed (i.e. private hospital location).

The use of hospital records in domestic properties is completely forbidden.

Hospital Records should not be taken to domestic properties under any

circumstances.

Storage accommodation for Health records must be clean and tidy in order to prevent damage to records.


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Patient Held Health Records It is normal practice in Community based services e.g.District Nursing and for pregnant ladies for some Health records to be held by the patient in their own home. Patients and/or carers should be advised as to the safe storage of these records. Records should be retrieved from the home on either discharge or death wherever possible. Irretrievable records must be reported via the incident reporting system.


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Appendix F

Tracking of all Paper Health Records Where a paper record has been created for a patient there should be documented evidence of its creation and movement. All electronic patient Health Records (PAS) should contain the details of all live and archived patient records and their storage location. It is a requirement of the Trust that the whereabouts of all records are known at all times. Case notes and records that are missing pose a significant risk to clinical care and loss of income due to the inability to code episodes of care and thereby affecting PbR. It is the responsibility of ALL individuals to ensure that the PAS system (LE2.2 / Lorenzo) is kept up to date in terms of the location of case notes. Every individual who handles and moves case notes is responsible for ensuring they are tracked accordingly. The Trust enquiries and tracking manual refers to this process. Tracking Health records for clinic use The recognised process for the use of case notes in clinic is that the record will be tracked to the clinic name and the date of clinic and the location in which the clinic is taking place. The notes would automatically be taken to the secretary following the clinic for the GP Correspondence to be typed. All records must remain in the designated clinic bundle and be stored clearly labelled in the secretarial office in this clinic bundle until the correspondence has been completed. After the correspondence is typed from the clinic bundle, the Health Record MUST be retracked. This includes records which are being retained by the secretary i.e for investigations. In such instances, the Records should be re-tracked stating their new location in the office (which should also be clearly identifiable). Case notes should be returned to their main storage location as soon as possible. When tracking case notes which are no longer needed the location for tracking should be the CURRENT destination, not where they will be going to. I.e. Medical Secretaries Room 2 – Comments. In RTF (return to file) box 1. Tracking records outside of the approved clinic use When a record is moved it should be tracked by the person handling the record. Patients can be treated as an emergency at any time, and it is essential that all records can be located in a timely manner. All tracking should take place in real time – as the record is moved. It is NOT acceptable to track records at a later date or time. Additionally, tracking should not be amended. This does not comply with audit processes. Where a record is moved, it should be re-tracked. All records should have the appropriate location selected, and specific details as to their whereabouts within the dedicated location. Where this description may include a specific shelf, storage location of desk, there areas must be clearly identifiable within the location.


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All individuals are responsible for the safe transfer of records and their retrieval. It is not the sole responsibility of the Health Records department. When tracking case notes, tracking should be completed from the original record. It is not permitted to write down local identifier numbers for the purpose of tracking. Without the record there is an increased risk of tracking the wrong record. Where a patient is transferring between ward areas (including from A&E) it is the responsibility of the department receiving the patient to track the case notes they receive with the patient. It is the responsibility of the admitting area, (or current area) to ensure all case notes are requested and transferred with the patient. Tracking or Archived Notes Retrieved / Reproduced for Identified High Risk Elective Admissions Where patients are referred for Anaesthetic review as part of the pre-operative assessment process, all archived records will be reproduced from Cd / retrieved from offsite storage for this purpose. All notes retrieved from off site will be tracked on the PAS system as normal. All copies reproduced from CD will be recorded manually as being reproduced, and should be retained with the case notes until the end of the episode. At the end of the episode the copy should be returned to Medical Records, where is will be recorded as returned and securely destroyed. Tracking Community Records

Where records are not tracked electronically via the computer systems it is essential to ensure that records are not misplaced or lost, each department must ensure that it has a system for tracking and tracing records Tracking systems should include the following information as a minimum: The item reference number or other identifier Brief description of the item Name of the person to whom the record is being sent, their department location and contact number Date of the transfer Expected date of return Name of the person recording the movement Any special instructions on return (e.g. forward to another department)

Training The Trust provides ‘enquiries and tracking’ training which provides the ability for all

individuals to track case notes. Anyone issued with a smart card should complete this

training.


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Appendix G Health Records Retention Schedule

This retention schedule details a Minimum Retention Period for each type of health record.

Records (whatever the media) may be retained for longer than the minimum period.

However, records should not ordinarily be retained for more than 30 years. Where a

retention period longer than 30 years is required (eg to be preserved for historical

purposes), or for any pre-1948 records, The National Archives (see note 1 below) should

be consulted. Organisations should remember that records containing personal

information are subject to the Data Protection Act 1998.

The following types of record are covered by this retention schedule (regardless of the

media on which they are held, including paper, electronic, images and sound, and

including all records of NHS patients treated on behalf of the NHS in the private

healthcare sector):

patient health records (electronic or paper-based, and concerning all

specialties, including GP medical records);

records of private patients seen on NHS premises;

Accident & Emergency, birth and all other registers;

theatre, minor operations and other related registers;

X-ray and imaging reports, output and images;

photographs, slides and other images;

microform (ie microfiche/microfilm);audio and video tapes, cassettes, CD-

ROMs, etc;

e-mails;

computerised records; and

scanned documents.

If viewed in electronic format, the search facility in Word or PDF can be used to search for

particular record types.

Notes

Where an organisation has an existing relationship with an approved Place of Deposit, it

should consult the Place of Deposit in the first instance. Where there is no pre-existing

relationship with a Place of Deposit, organisations should consult The National Archives.

The coding below denotes the status of the type of record and its retention period:

C = a previously existing record type (ie referenced in the previous retention schedule

dated March 2006) but a Change to the retention period


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N =a New record type (either not referenced in the previous retention schedule or a more

explicit description of a record type than previously published)

S = a previously existing record type, with the Same retention period.


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TYPE OF HEALTH

RECORD

MINIMUM RETENTION PERIOD DERIVATION FINAL ACTION CODE

(see note

2)

A&E records (where

these are stored

separately from the

main patient record)

Retain for the period of time appropriate to the

patient/specialty, eg children’s A&E records should be

retained as per the retention period for the records of

children and young people

Destroy under

confidential

conditions

S

A&E registers (where

they exist in paper

format)

8 years after the year to which they relate

Likely to have

archival value.

See note 1

S

Abortion – Certificate

A (Form HSA1) and

Certificate B

(Emergency Abortion)

3 years

Destroy under

confidential

conditions

S

Admission books

(where they exist in

paper format)

8 years after the last entry

Likely to have

archival value.

See note 1

S

Adoption records

(administrative) – see

non‑ health records


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TYPE OF HEALTH

RECORD


(see note

2)

Pre-Adoption Records

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 25th birthday or 26th 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

Destroy under

confidential

conditions

N

Ambulance records –

patient identifiable

component (including

paramedic records

made on behalf of the

Ambulance Service)

10 years

(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)

Limitation Act

Destroy under

confidential

conditions

N

Angiography tapes

and disks

8 years

Destroy under

confidential

conditions

N

Asylum seekers and

refugees (NHS

Special NHS record – patient held – no requirement on

NHS to retain

S


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TYPE OF HEALTH

RECORD


(see note

2)

personal health record

– patient-held record)

Audio tapes of calls

requesting care (PCT,

GP, NHS Direct

Records etc)

Retain taped calls for 3 years providing all relevant clinical

information has been transferred to the appropriate

patient record.

Where the information is NOT transferred into a health

record, the tapes should be retained for 10 years.

Limitation Act 1980

Destroy under

confidential

conditions

N

Audiology records


patient/specialty, eg 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

Destroy under

confidential

conditions

S

Audit Trails

(Electronic Health

Records)

NHS organisations are advised to retain all audit trails

until further notice.

Destroy under

confidential

conditions

N

Autopsy records – see

Post mortem records

and registers


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TYPE OF HEALTH

RECORD


(see note

2)

Birth registers (ie

register of births kept

by the hospital)

Lists sent to General Register Office on a monthly basis.

Retain for 2 years

Likely to have

archival value.

See note 1

S

Birth Notification (to

Child Health

Department)



death.

Destroy under

confidential

conditions

N

Blood transfusion

records (see

pathology records)

Body release forms

2 years

Destroy under

confidential

conditions

S

Breast screening

X-rays

(see Mammography

Screening)

Care records –

compiled by



Destroy under

confidential

S


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TYPE OF HEALTH

RECORD


(see note

2)

employees of a Care

Trust (including

information on an

individual’s

educational status,

care needs, etc)






conditions

Cervical screening

slides

10 years

Destroy under

confidential

conditions

S

Chaplaincy records

2 years

Likely to have

archival value.

See note 1

S

Child and family

guidance








Destroy under

confidential

conditions

S

Child Health Record Retain until the patient’s 25th birthday or 26th if young


Destroy under

confidential

N


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TYPE OF HEALTH

RECORD


(see note

2)





longer period

conditions

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 25th birthday or 26th birthday if an

entry was made when the patient was 17 or 10 years

after the patient’s death if patient died while 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.

Destroy under

confidential

conditions

N

Child Protection

Register (records

relating to)

Retain until the patient’s 26th birthday or 8 years after the

patient’s death if patient died while in the care of the

organisation

Destroy under

confidential

conditions

C

Children and young

people (all types of

records relating to

children and young




relevance to adult conditions or have genetic implications,

Destroy under

confidential

conditions

S


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TYPE OF HEALTH

RECORD


(see note

2)

people)

the advice of clinicians should be sought as to whether to

retain the records for a longer period

Clinical audit records

5 years

Destroy under

confidential

conditions

S

Clinical Protocol (GP,

in-house)

25 years

Destroy under

confidential

conditions

N

Clinical psychology

20 years

See note 1

C

Clinical trials (see

research records)

Contraception and

Sexual Health

Records

(Including where a

scan is undertaken

prior to termination of

pregnancy but the

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

See also Guidance on the Retention and Disposal of

Hospital Notes, British Association for Sexual Health and

HIV (BASHH)

http://www.bashh.org/committees/cgc/servicespec/guidan

Clinical Standards

Committee,

Faculty of Sexual and

Reproductive Healthcare

(FSRH) of the Royal

College of Obstetricians

and Gynaecologists

N


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TYPE OF HEALTH

RECORD


(see note

2)

patient goes

elsewhere for the

procedure)

ce_retention_disposal_notes_0606.pdf. NB The longest license

period for a

contraceptive device is

10 years

Controlled drug

documentation

(Moved from

Pharmacy Records)

Requisitions – 2 years

Registers and CDRBs – 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 CDs – 7 years

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/ websites for up-to-date

information

Misuse of Drugs Act

1971

Misuse of Drugs

Regulations 2001

Safer management of

controlled drugs: a guide

to good practice in

secondary care

(England). October

2007, Dept of Health,

17th October 2007

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

Publicationsandstatistics

/

Publications/Publications

Policy

AndGuidance/DH_07961

8

Destroy under

confidential

conditions

N

Counselling records

20 years or 8 years after the patient’s death if patient died

while in the care of the organisation

Guidance for best

practice: the

employment of

counsellors and

See note 1

C


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TYPE OF HEALTH

RECORD


(see note

2)

psychotherapists in the

NHS, British Association

for Counselling and

Psychotherapy (BACP)

2004

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

Creutzfeldt-Jakob

Disease (hospital and

GP)

30 years from date of diagnosis, including deceased

patients

CJD Incidents Panel

See note 1

S

Death – Cause of,

Certificate counterfoils

2 years

Destroy under

confidential

conditions

S

Death registers – ie

register of deaths kept

by the hospital, where

Lists sent to GRO on a monthly basis. Retain for 2 years

Death registers prior to lists sent to GRO – offer to Place

of Deposit

Likely to have

archival value.

See note 1

S


Page 43 of 133

TYPE OF HEALTH

RECORD


(see note

2)

they exist in paper

format

Dental

epidemiological

surveys

30 years

Destroy under

confidential

conditions

S

Dental, ophthalmic

and auditory

screening records

including Orthodontic

Records and Models

Community Records

11 years for adults

For children 11 years or up to their 25th birthday,

whichever is the longer

Hospital Records

Adult records – Retain for 8 years

Children and young people – Retain until the patient’s

25th birthday or26th 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

British Dental

Association

Destroy under

confidential

conditions

N

De-registered patients

(received by PCT’s) –

records for

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.

Destroy under

confidential

conditions

N


Page 44 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Diagnostic Image

Data (for diagnostic

imaging undertaken in

the private sector

under contract to the

NHS or private

providers treating

patients on behalf of

the NHS)

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.

National Diagnostic

Imaging Services

Contract; Records

Management: NHS

Code of Practice

N

Diaries – health

visitors, district nurses

and Allied Health

Professionals

2 years after end of year to which diary relates. Patient

specific 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.

Destroy under

confidential

conditions

N

Did not attend (DNA)

see DNA below

Dietetic and nutrition






Destroy under

confidential

conditions

N


Page 45 of 133

TYPE OF HEALTH

RECORD


(see note

2)



Discharge books


paper format)

8 years after the last entry

Likely to have

archival value.

See note 1

S

Discharge nursing

team assessments of

homes and nursing

homes

NB The documents

should be part of the

patient record as they

relate to the discharge

of the patient








N

District nursing

records








Destroy under

confidential

conditions

S

DNA (health records Where there is a letter or correspondence informing the Destroy under N


Page 46 of 133

TYPE OF HEALTH

RECORD


(see note

2)

for patients who did

not attend for

appointments as out-

patients)

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,

eg 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.

confidential

conditions

Donor records (blood

and tissue)

30 years post transplantation

Committee on

Microbiological Safety of

Blood and Tissues for

Transplantation (MSBT);

guidance issued in 1996

See note 1

S

Drug trials, records

(see Research

records)


Page 47 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Duplicate patient

record notification

forms (NHS Direct)

2 years after the decision of whether or not to merge

unless there is a business need to retain for longer.

Destroy under

confidential

conditions

N

Electrocardiogram

(ECG) Records

7 years

NB 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

records.

Destroy under

confidential

conditions

N

Endoscopy Records

including:

Sterilix Endoscopic

Disinfector

Traceability Strips,

Traceability Stickers

for PEG/Stents

(Endoscopy)

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 25th birthday or 26th 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.

Destroy under

confidential

conditions

N

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 25th 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 persons should be retained for 8

Clinical Standards

Committee,



(FSRH) of the Royal


and Gynaecologists

Destroy under

confidential

conditions

C


Page 48 of 133

TYPE OF HEALTH

RECORD


(see note

2)

years after death NB The longest license

period for a


10 years

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)

See also Human

tissue, Post mortem

registers

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

The Retention and

Storage of Pathological

Records and Archives

(3rd edition 2005)

guidance from the Royal

College of Pathologists

and the Institute of

Biomedical Science:

http://www.rcpath.org.uk/

resources/pdf/retention-

SEPT05.pdf

Human Tissue Act 2004

See note 1

S

Genetic records

30 years 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

See note 1

S


Page 49 of 133

TYPE OF HEALTH

RECORD


(see note

2)

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 records of adults - retain for 10 years after last entry

For clients under 18 - retain until 25th 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 persons should be retained for 8

years after death



HIV (BASHH)


ce_retention_disposal_notes_0606.pdf.

Clinical Standards

Committee,



(FSRH) of the Royal


and Gynaecologists

Destroy under

confidential

conditions

C

GP records, including

medical records

relating to HM Armed

Forces or those

serving a period of

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

Destroy under

confidential

conditions

S


Page 50 of 133

TYPE OF HEALTH

RECORD


(see note

2)

imprisonment




longer period

Maternity records – 25 years after last live birth

Records relating to persons receiving treatment for a

mental disorder within the meaning of the Mental Health

Act 1983 –20 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 then be

summarised and kept in summary format for the

additional 10-year period

Limitation Act 1980,

Congenital Disabilities

(Civil Liability) Act 1976,

Consumer Protection

Act 1987

Royal College of

Psychiatrists

Destroy under

confidential

conditions

Destroy under

confidential

conditions

S

S

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 –

Not to be destroyed.

This refers to GP

records of serving

military personnel

that were

inexistence prior to

them enlisting.

Following the death

of the patient, the

S


Page 51 of 133

TYPE OF HEALTH

RECORD


(see note

2)

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

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.

S

Electronic patient records (EPRs) must not be destroyed,

or deleted, for the foreseeable future

Good Practice

Guidelines for General

Practice Electronic

Patient Records

(version 3.1)

Destroy under

confidential

conditions

S

Health visitor records

10 years. Records relating to children should be retained

until their 25th birthday

Destroy under

confidential

conditions

S

Homicide/’serious

untoward incident’

30 years

See note 1

S


Page 52 of 133

TYPE OF HEALTH

RECORD


(see note

2)

records

Hospital acquired

infection records

6 years

Destroy under

confidential

conditions

S

Hospital records (i.e.

other non-specific,

secondary care

records that are not

listed elsewhere in

this schedule)

8 years after conclusion of treatment or death

Destroy under

confidential

conditions

N

Human fertilisation

records, including

embryology records

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.

HFEA Data Protection

Policy Version 2 Release

Date 27/07/2007

http://www.hfea.gov.uk/d

ocs/DP_Policy_-

_web.pdf

See note 1

S

Storage centres

Where gametes, etc have been used in research, records

Directions given under

the Human Fertilisation

S


Page 53 of 133

TYPE OF HEALTH

RECORD


(see note

2)

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)

and Embryology Act

1990, 24 January 1992

(this Act is subject to

review by the

Government:

http://www.dca.gov.uk/St

atutoryBars

Report2005.pdf)

This applies to centres in

respect of information

which they are directed

to record and maintain

under a

treatment/storage

licence.

S

Human tissue (within

the meaning of the

Human Tissue Act

2004) (see Forensic

medicine above)

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

S

Immunisation and

vaccination records

For children and young people – retain until the patient’s

25th birthday or 26th if the young person was 17 at

conclusion of treatment

All others retain for 10 years after conclusion of treatment

Destroy under

confidential

conditions

S

Intensive Care Unit Retain for the period of time appropriate to the Destroy under S


Page 54 of 133

TYPE OF HEALTH

RECORD


(see note

2)

charts







confidential

conditions

Joint replacement

records

10 years

For joint replacement surgery the revision of a primary

replacement may be required after 10 years and there is

a need to identify which prothesis was used originally.

There is only a need to retain the minimum of notes with

specific information about the original prosthesis for the

full 10 years

http://www.njrcentre.org.

uk

Consumer Protection

Act (CPA) 1987 &

Section 11A(3)

Limitation Act 1980 (in

accordance with Section

4 CPA)

See note 1

C

Learning difficulties –

(records of patients

with)

NB Specific Learning

Difficulty is where a

person finds one

particular thing difficult

but manages well in

everything else







death if patient died whilst in the care of the organisation

Royal College of

Psychiatrists

Destroy under

confidential

conditions

C

Learning Disabilities

NB A general learning



Royal College of

Psychiatrists

Destroy under

confidential

N


Page 55 of 133

TYPE OF HEALTH

RECORD


(see note

2)

disability is not a

mental illness – it is a

life-long condition,

which can vary in

degree from mild to

profound





death if patient died whilst in the care of the organisation

conditions

Macmillan (cancer

care) patient records–

community and acute








Destroy under

confidential

conditions

S

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 is involved – 11 years

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

BFCR(06)4 Royal

College of Radiologists

Consumer Protection

Act 1981

Destroy under

confidential

conditions

N


Page 56 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Maternity (all obstetric

and midwifery

records, including

those of episodes of

maternity care that

end in stillbirth or

where the child later

dies)

25 years after the birth of the last child

See Addendum 1

(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

Destroy under

confidential

conditions

S

Medical illustrations

(see Photographs

below)








Destroy under

confidential

conditions

S

Mental Health

Records – Child &

Adolescent (includes

clinical psychology

records) not listed

elsewhere in this

20 years from the date of last contact, or until their

25th/26th birthday, whichever is the longer period.

Retention period for records of deceased persons is 8

years after death.

Destroy under

confidential

conditions

N


Page 57 of 133

TYPE OF HEALTH

RECORD


(see note

2)

schedule

Mentally disordered

persons (within the

meaning of any

Mental Health Act)

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 (local

decision). Records must be kept as complete records for

the first 20 years in accordance with this retention

schedule but records may then be summarised and kept

in summary format for the additional 10-year period. This

retention period has been intentionally left 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

Mental Health Act 1983

and its successors

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

N

Microfilm/microfiche Retain for the period of time appropriate to the May have archival S


Page 58 of 133

TYPE OF HEALTH

RECORD


(see note

2)

records relating to

patient care







value. See note 1

Midwifery records

25 years after the birth of the last child

Midwives rules and

standards 05.04 (rule 9)

Destroy under

confidential

conditions

S

Mortuary registers


paper format)

10 years

See note 1

S

Music therapy records








Destroy under

confidential

conditions

S

Neonatal screening

records

25 years Destroy under

confidential

S


Page 59 of 133

TYPE OF HEALTH

RECORD


(see note

2)

conditions

Nicotine Replacement

Therapy (dispensed

as smoking cessation

aid)

2 years unless there are clinical indications to keep them

for longer

Destroy under

confidential

conditions

N

Notifiable diseases

book

6 years

Destroy under

confidential

conditions

S

Occupational health

records (staff)

3 years after termination of employment unless litigation

ensues (see Litigation)

Destroy under

confidential

conditions

S

Health records for

classified persons

under medical

surveillance

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


Control of Substances

Hazardous to Health

Regulations 2002 (reg.

24(3))

See note 1

S

Personal exposure of

an identifiable

employee monitoring

40 years from exposure date

See above

(reg. 10(5))

See note 1

S


Page 60 of 133

TYPE OF HEALTH

RECORD


(see note

2)

record

Personnel health

records under

occupational

surveillance

40 years from last entry on the record

Ionising Radiation

Regulations 1999

(reg. 11(3))

See note 1

S

Radiation dose

records for classified

persons

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


See above

(reg. 19(3)(a))

See note 1

S

Occupational therapy

records








Destroy under

confidential

conditions

S

Occupationally

Related Diseases e.g.

asbestosis,

pneumoconiosis,

byssinosos)

10 years after date of last entry in the record

British Thoracic

Society’s Occupational

and Environmental Lung

Disease Specialist

Advisory Group

Destroy under

confidential

conditions

N


Page 61 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Oncology (including

radiotherapy)

30 years

The 30 year retention period is the period required by the

Public Records Act whereby organisations, which need to

retain records for greater than 30 years should consult

with their Local Place of Deposit (see note 1 – final action

column). For deceased patients records should be

retained for 8 years after death.

NB Records should be retained on a computer database

if possible. Also consider the need for permanent

preservation for research purposes

BFCO (96)3 issued by

the Royal College of

Radiologists with the

support of the Joint

Council for Clinical

Oncology

See note 1

S

Operating Theatre

Lists (paper)

4 years (for those lists that only exist in paper format and

are the sole record)

48 hours (for prints taken from computer records)

N

Operating theatre

registers


Likely to have

archival value.

See note 1

S

Orthoptic records








Destroy under

confidential

conditions

S


Page 62 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Orthotic records

8 years after conclusion of treatment or death

Destroy under

confidential

conditions

N

Outpatient lists (where

they exist in paper

format)


Destroy under

confidential

conditions

S

Paediatric records

(see Children and

young people above)

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.

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’s25th birthday, or 26th

birthday if the young person was 17 at the conclusion of

treatment, or 8 years after death

Destroy under

confidential

conditions

N


Page 63 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Pathology records

Documents, electronic

and paper records

Accreditation

documents; records of

inspections

10 years or until superseded

http://www.rcpath.org/res

ources/pdf/retention-

SEPT05.pdf

The retention schedules

are under review by the

Royal College of

Pathologists – check

RCP website for updates

Destroy under

confidential

conditions

S

Batch records results

(relating to products)

10 years

Consumer Protection

Act 1987

N

Blood gas results








N

Bound copies of

reports/records, if

made

30 years

S


Page 64 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Day books and other

records of specimens

received by a

laboratory

2 calendar years

S

Equipment/instrument

s 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

S

S

External quality

control records

2 years

S

Internal quality control

records (relating to

products)

10 years

Consumer Protection

Act 1987

S

Lab file cards or other

working records of

2 calendar years S


Page 65 of 133

TYPE OF HEALTH

RECORD


(see note

2)

test results for named

patients

Near-patient test data

Result in patient record, log retained for lifetime of

instrument

S

Pathological

archive/museum

catalogues

30 years, subject to consent

S

Photographic records

30 years where images present the primary source of

information for the diagnostic process

S

Records of

telephoned reports

2 calendar years

S

Records relating to

investigation or

storage of specimens

relevant to organ

transplantation,

semen or ova

30 years if not held with health record

S


Page 66 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Reports, copies

Post mortem reports

6 months

Held in the patient’s health record for 8 years after the

patient’s death

S

Request forms that

are not a unique

record

1 week after report received by requestor

S

Request forms that

contain clinical

information not readily

available in the health

record

30 years

S

Standard operating

procedures (current

and old)

30 years

S

Specimens and

preparations

Blocks for electron

microscopy

30 years

S

Electrophoretic strips

and immunofixation

5 years unless digital images taken, in which case 2 years

and stored as a photographic record

S


Page 67 of 133

TYPE OF HEALTH

RECORD


(see note

2)

plates

Foetal serum

30 years

S

Frozen tissue for

immediate histological

assessment (frozen

section)

Stained microscope slides – 10 years

Residual tissue – kept as fixed specimen once frozen

section complete

S

Frozen tissue or cells

for histochemical or

molecular genetic

analysis

10 years

S

Grids for electron

microscopy

10 years

S

Human DNA

4 weeks after final report for diagnostic specimens. 30

years for family studies for genetic disorders (consent

required)

S

Microbiological 24–28 hours after final report of a positive culture issued. C


Page 68 of 133

TYPE OF HEALTH

RECORD


(see note

2)

cultures

7 days for certain specified cultures – see RCPath

document

Museum specimens

(teaching collections)

Stained slides

Permanently. Consent of the relative is required if it is

tissue obtained through post mortem

Depends on the purpose of the slide – see RCPath

document for further details

http://www.rcpath.org/res

ources/pdf/Retention-

SEPT05.pdf

S

Newborn blood spot

screening cards

Body

fluids/aspirates/swabs

5 years – parents should be alerted to the possibility of

contact from researchers after this period and a record

kept of their consent to contact response

48 hours after the final report issued by lab

Code of Practice of the

UK Newborn Screening

Programme Centre and

http://www.screening.nh

s.uk/cpd/ICFactsheet4.p

df

S

Paraffin blocks

30 years and then appraise for archival value

S

Records relating to

donor or recipient

sera

11 years post transplant

S

Serum following

needlestick injury or

hazardous exposure

2 years

S


Page 69 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Serum from first

pregnancy booking

visit

1 year

S

Wet tissue

(representative aliquot

or whole tissue or

organ)

4 weeks after final report for surgical specimens

Human Tissue Act

S

Whole blood samples,

for full blood count

24 hours

S

Transfusion

laboratories

Annual reports (where

required by EU

directive)

15 years

S

Autopsy reports,

specimens, archive

material and other

where the deceased

has been the subject

of a Coroner’s

These are Coroner’s records – copies may only be

lodged on the health record with the Coroner’s permission

S


Page 70 of 133

TYPE OF HEALTH

RECORD


(see note

2)

autopsy

Blood bank register,

blood component

audit trial and fates

30 years to allow full traceability of all blood products

used

EU Directive N

2002/98/EC The Blood

Safety and Quality

Regulations 2005 (SI

2005 No. 50)

S

Blood for grouping,

antibody screening

and saving and/or

cross-matching

1 week at 4ºC

S

Forensic material –

criminal cases

Permanently, not part of the health record

S

Refrigeration and

freezer charts

11 years

S

Request forms for

grouping, antibody

screening and

crossmatching

1 month

EU Directive 2002/98/EC

The Blood Safety and

Quality Regulations 2005

(SI 2005 No. 50)

S


Page 71 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Results of grouping,

antibody screening

and other blood

transfusion-related

tests


used




(SI 2005 No. 50)

S

Separated

serum/plasma, stored

for transfusion

purposes

Up to 6 months

S

Storage of material

following analyses of

nucleic acids

30 years

See RCPath document for further guidance

http://www.cepath.org/es

ources/pdf/Retention-

SEPT05.pdf

S

Worksheets


used




(SI 2005 No. 50)

S

Patient-held records

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

Destroy under

confidential

S


Page 72 of 133

TYPE OF HEALTH

RECORD


(see note

2)

to retrieve patient-held records. The records should then

be retained for the period appropriate to the specialty

conditions

Pharmacy records

Prescriptions

Chemotherapy

Recommendations for the retention of pharmacy records

(prepared by the NHS East of England Senior Pharmacy

Manager’s Network). Notes at the beginning of the

retention schedule.

2 years after last treatment

(Electronic Patient Records will eventually hold all details)

http://www.pjonline.com//

news/recommendations

_for_the_retention_of_p

harmacy_records

Destroy under

confidential

conditions

S

Clinical drug trials

(non-sponsored)

2 years after the end of the trial

S

FP10, TTOs,

outpatient, private

2 years

(Electronic Patient Records will eventually hold all details)

NB Inpatient

prescriptions held

as part of health

record

N

Parenteral nutrition

2 years

(Original valid prescriptions should be kept in patient’s

notes)

N

Unlicensed medicines

dispensing record

5 years

(Requirement of MHRA Guidance Note No. 14.

Permanent record of batch details kept)

MHRA Guidance Note

No. 14

N


Page 73 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Worksheets

Raw material request

and control forms

At least 5 years

(Part of batch record, so product liability issues apply)

S

Resuscitation box

1 year after the expiry of the longest dated item

Applies only to

repackaged items (e.g.

ampoules separated

from outer packaging)

S

Chemotherapy,

aseptics worksheets,

parenteral nutrition,

production batch

records

5 years

(Product liability extends this to 11 years after expiry)

Product liability extends

up to 11 years after

expiry

S

Paediatric

At least 5 years

See Note 6, Appendix ii)

Product liability extends

up to 28 years

S

Quality Assurance

Environmental

monitoring results

1 year after expiry date of products

As electronic record – in perpetuity

S

Equipment validation

Lifetime of the equipment

S


Page 74 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Quality Control

documentation,

certificates of analysis

5 years or 1 year after expiry of batch (whichever is

longer)

Article 51(3)

Directive 2001/83

S

Refrigerator

temperature

1 year

(Refrigerator records to be retained for the life of any

product stored therein, particularly vaccines)

S

Standard operating

procedures

15 years

As electronic record – in perpetuity

S

Orders

Invoices

6 years


Limitation Act 1980

S

Order and delivery

notes, requisition

sheets, old order

books

2 years

Current financial year plus one


S

Picking

tickets/delivery notes

3 months

(i.e. a “reasonable period” – for verification of order only)

S

Ward pharmacy 1 year Limitation Act 1980 S


Page 75 of 133

TYPE OF HEALTH

RECORD


(see note

2)

requests

(Record of what was requested by ward pharmacist –

unlikely benefit after 12 months)

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.








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.

Destroy under

confidential

conditions

N

Physiotherapy records








Destroy under

confidential

conditions

S

Podiatry records




Destroy under

confidential

conditions

S


Page 76 of 133

TYPE OF HEALTH

RECORD


(see note

2)





Post mortem records

(see Pathology

records)

Post mortem registers


paper format)

30 years

Likely to have

archival value.

See note 1

S

Prison healthcare

records (see also GP

records)

Where hospital letters for serving prisoners are scanned

into the Prison Health computer system and the paper

copy is also filed into the paper records the paper copy

may be destroyed once it has been scanned into the

system providing the scanning process and procedures

are compliant with BSI’s “BIP:0008 – Code of Practice for

Legal Admissibility and Evidential Weight of Information

Stored Electronically”. Once the letters have been

scanned they can be destroyed under confidential

conditions.

Destroy under

confidential

conditions

C

Private patient Although technically exempt from the Public Records Destroy under S


Page 77 of 133

TYPE OF HEALTH

RECORD


(see note

2)

records admitted

under section 58 of

the National Health

Service Act 1977 or

section 5 of the

National Health

Service Act 1946

Acts, it would be appropriate for authorities to treat such

records as if they were not so exempt and retain for

period appropriate to the specialty

confidential

conditions

Psychology records

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

care of the organisation

See note 1

C

Psychotherapy

Records

20 years or 8 years after the patient’s death if patient died

while in the care of the organisation

Guidance for best

practice: the

employment of

counsellors and

psychotherapists in the

NHS, British Association

for Counselling and

Psychotherapy (BACP)

2004

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

Destroy under

confidential

conditions

N


Page 78 of 133

TYPE OF HEALTH

RECORD


(see note

2)

are subject to the

retention periods in this

schedule

Records/documents

related to any litigation

As advised by the organisation’s legal advisor. All records

to be reviewed. Normal review 10 years after the file is

closed

See note 1

S

Records of

destruction of

individual health

records (case notes)

and other health-

related records

contained in this

retention schedule (in

manual or computer

format)

Permanently

BS ISO 15489

(section 9.10)

See note 1

S

Recovery Room

Registers

(Operating Theatre)

8 years

May have archival value.

See note 1

Destroy under

confidential

conditions

N

Referral letters (for

patients who are

treated by the

Referral letters should be filed in the patient/client service

user’s health record, which contains the record of

treatment and/or care received for the condition for which

Destroy under

confidential

conditions

N


Page 79 of 133

TYPE OF HEALTH

RECORD


(see note

2)

organisation to which

they were referred)

the referral was made. This will ensure that the patient

record is a complete record. These records should then

be retained for the period of time appropriate to the







Referral letters for

clients referred to

health or care

services but not

accepted.

Where there is a letter or correspondence detailing the

reasons for non-acceptance that goes to the organisation

that has referred the client, so the information is also held

elsewhere. Retain for 2 years after the decision is made.

Where there is no letter or correspondence detailing the

reasons for non-acceptance that goes to the organisation

that has referred the client. Retain for the period of time

appropriate to the patient/specialty, eg 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.

Referrals to the Clinical Assessment Service (who deal

with our referrals to the therapy services), where the

patient never followed up the initial referral from the G.P.,

and thus have no clinical or patient history with that

service. Where the GP has been informed that the patient

Destroy under

confidential

conditions

N


Page 80 of 133

TYPE OF HEALTH

RECORD


(see note

2)

failed to attend and if all the information held in these files

is non-clinical and is also held electronically on a

computer system or held elsewhere the referrals can be

destroyed.

Referral letters (to

PCT clinical service

e.g. ECG) where the

results are sent back

to GP’s

Referral letters –

where the

appointment was

cancelled by the

patient before the

referral letter was

included in the patient

record (i.e. before the

clinic preparation

process)

2 years

Where a letter is sent to the referring clinician detailing

the reason(s) why the patient/client cancelled the

appointment retain for 2 years after the date the

appointment was cancelled.

Where there is no letter or correspondence detailing the

reasons for the patient not attending for their appointment

that goes to the clinician that referred the patient/client.







death if patient died while in the care of the organisation.

Destroy under

confidential

conditions

Destroy under

confidential

conditions

N

N

Research Records

1. Clinical Trials of

Investigational

Medicinal Products

(CTIMPs)

N


Page 81 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Trial Master File

(responsibility of

Sponsor & Chief

Investigator to ensure

that documents are

retained)

Research Ethics

Committee Records

Trial Subject’s

Medical Files

(Sponsor & Chief

Investigator’s

responsibility to

ensure retained)

Five years after the conclusion of the trial

An ethics committee shall retain all the documents

relating to a clinical trial on which it gives an opinion for:

(a) where the trial proceeds, at least three years from the

conclusion of the trial: or

(b) where the trial does not proceed, at least three years

from the date of the opinion.

Five years after the conclusion of the trial

There should be a flag or divider in health records

for documents pertaining to research indicating that the

patient has been recruited to a clinical trial or

other research

The Medicines for

Human Use (Clinical

Trials) Amendment

Regulations 2006 –

sections 18 and 28.

Governance

Arrangements for NHS

Research Ethics

Committees (GAfREC)

Destroy under

confidential

conditions

Destroy under

confidential

conditions

Destroy under

confidential

conditions

N

C

C

Marketing

authorisation (holders

must arrange for

essential clinical trial

documents (including

case report forms)

other than subject’s

medical files, to be

kept by the owners of

the data):

15 yrs after completion or discontinuation of the trial,

or

Two years after the granting of the last marketing

authorisation in the European Community and when there

are no pending or contemplated marketing applications in

the European Community,

or

two years after formal discontinuation of clinical

development of the investigational product.

COMMISSION

DIRECTIVE 2003/63/EC

(brought into UK law by

inclusion in The

Medicines for Human

Use (Fees and

Miscellaneous

Amendments)

Regulations 2003) –

section 5.2(c).

Destroy under

confidential

conditions

N


Page 82 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Trial subject’s medical

files

Retain in accordance with applicable legislation and in

accordance with the maximum period of time permitted

by the hospital, institution or private practice

NB Documents can be retained for a longer period,

however, if required by the applicable regulatory

requirements or by agreement with the sponsor. It is the

responsibility of the sponsor to inform the hospital,

institution or practice as to when these documents no

longer need to be retained.

Destroy under

confidential

conditions

N

All other

documentation

pertaining to the trial

(retention of

documentation is the

responsibility of the

sponsor or other

owner of the data)

Final Report

(responsibility of

sponsor or

subsequent owner’s

to retain documents)

Retain as long as the product is authorised.

Five years after the medicinal product is no longer

authorised.

Destroy under

confidential

conditions

Destroy under

confidential

conditions

N

2. Data Collected in

the Course of

Research

Data collected in the

Retain for an appropriate period, to allow further analysis

Research Governance

Destroy under

N


Page 83 of 133

TYPE OF HEALTH

RECORD


(see note

2)

course of research by the original or other research teams subject to

consent, and to support monitoring by regulatory and

other authorities.

Framework for Health

and Social Care –

paragraph 2.3.5.

Good Research Practice

(MRC Ethics Series,

2000, updated 2005) –

paragraph 5.2.

Personal Information in

Medical Research (MRC

Ethics Series, 2000,

updated 2003) –

chapter 7.

Data Protection Act 1998

– Part IV, Section 33 (3).

confidential

conditions

Risk Assessment

Records

Retain the latest risk assessment until a new one

replaces it.

N

Scanned records

relating to to patient

care







death if patient died while in the care of the organisation.

NB Providing the scanning process and procedures are

compliant with BSI’s BIP:0008 – Code of Practice for

Legal Admissibility and Evidential Weight of Information

Destroy under

confidential

conditions

S


Page 84 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Stored Electronically once the casenotes have been

scanned the paper records can be destroyed under

confidential conditions.

School health records

(see Children and

young people)

Sexual Health

Records

10 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



HIV (BASHH)


ce_retention_disposal_notes_0606.pdf.

Clinical Standards

Committee, Faculty of

Sexual and


(FSRH) of the Royal


and Gynaecologists

NB The longest license

period for a


10 years

Destroy under

confidential

conditions

N

Smoking Cessation

Records

2 years unless there are clinical indications to keep them

for longer

NB PCT’s should consider whether they need to retain

these records for a longer period if any medication etc is

dispensed.

Destroy under

confidential

conditions

N

Speech and language

therapy records



Destroy under

confidential

S


Page 85 of 133

TYPE OF HEALTH

RECORD


(see note

2)






conditions

Suicide – notes of

patients having

committed suicide

10 years

See note 1

S

Temporary Resident’s

Forms (GMS 3/99)

2 years

NB Temporary GPs should maintain a record of episodes

of treatment and diagnoses as well as sending a copy to

the patient’s normal GP

Destroy under

confidential

conditions

N

Transplantation

records

Records not otherwise kept or issued to patient records

that relate to investigations or storage of specimens

relevant to organ transplantation should be kept for 30

years

The Retention and

Storage of Pathological

Records and Archives

(3rd edition 2005)

Addendum 1

See note 1

C

Ultrasound records

(eg vascular,

obstetric)






Destroy under

confidential

conditions

S


Page 86 of 133

TYPE OF HEALTH

RECORD


(see note

2)



Vaccination records

(see Immunisation

and vaccination

records)

Video records/voice

recordings relating to

patient care/video

records/video-

conferencing records

related to patient

care/DVD records

related to patient care

Includes:

Telemedicine records

Out of hours records

(GP cover)

NHS Direct records

8 years subject to the following exceptions or where there

is a specific statutory obligation to retain records for

longer periods:

Children and young people:

Records must be kept until the patient’s 25th birthday, or

if the patient was 17 at the conclusion of treatment, until

their 26th birthday, or until 8 years after the patient’s

death if sooner

Maternity:

25 years

Mentally disordered persons:

Records should be kept for 20 years after the date of last

contact between patient/client/service user and any

healthcare professional or 8 years after the patient’s

death if sooner

Cancer patients:

Records should be kept until 8 years after the conclusion

Guidance on use of

video-conferencing in

healthcare:

http://www.wales.nhs.uk/

sites/documents/351/1_

multipart_xF8FF_3_Guid

ance%20on%20the%20

Use%20of%20Videoconf

erencing%20in%20Healt

hcare%20_Ve_.pdf

The teaching and

historical value of

such recordings

should be

considered,

especially where

innovative

procedures or

unusual conditions

are involved.

Video/video-

conferencing

records should be

either permanently

archived or

permanently

destroyed by

shredding or

incineration (having

due regard to the

N


Page 87 of 133

TYPE OF HEALTH

RECORD


(see note

2)

of treatment, especially if surgery was involved. The

Royal College of Radiologists has recommended that

such records be kept permanently where chemotherapy

and/or radiotherapy was given

need to maintain

patient

confidentiality).

Vulnerable Adults

(records for)

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

patients’ health or social care record held at the receiving

organisation and they should then be retained for the

period of time appropriate to the specialty.

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.

Destroy under

confidential

conditions

N

Ward registers,

including daily bed

returns (where they

exist in paper format)


Likely to have

archival value.

See note 1

S

X-ray films (including

other image formats

for all imaging

modalities/diagnostics

)

General Patient Records – 8 years after conclusion of

treatment

Children & Young People – Until the patient’s 25th

birthday, or if the patient was 17 at conclusion of

treatment, until their 26th birthday or 8 years after the

patient’s death if sooner.

BFCR(06)4 – Royal


Guidance from the Royal


regards “images and

request information (to

Destroy under

confidential

conditions

N


Page 88 of 133

TYPE OF HEALTH

RECORD


(see note

2)

Maternity – 25 years after the birth of the child, including

still births

Clinical Trials – 15 years after completion of treatment

Litigation – 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.

Mental Health – 20 years after no further treatment

considered necessary or 8 years after death.

Oncology – see Oncology Records

be) of a transitory

nature” (para 2.1), but

goes on to say: “It is now

considered that best

practice should move

towards retention of

image data for the same

duration as report and

request data” (para 2.2)

and recommends that

“the retention period for

text and image data are

equal and comply with

the published retention

schedules” (para 7.1):

http://www.rcr.ac.uk/inde

x.asp?PageID=310&Pub

licationID=234

X-Ray

Referral/Request

Cards

8 years providing there is a record in the patient’s health

record that a referral/ request was made for an x-ray

Guidance from the Royal


regards “images and

request information (to

be) of a transitory

nature” (para 2.1), but

goes on to say: “It is now

considered that best

practice should move

towards retention of

image data for the same

Destroy under

confidential

conditions

N


Page 89 of 133

TYPE OF HEALTH

RECORD


(see note

2)

duration as report and

request data” (para 2.2)

and recommends that

“the retention period for

text and image data are

equal and comply with

the published retention

schedules” (para 7.1):

http://www.rcr.ac.uk/inde

x.asp?PageID=310&Pub

licationID=234

X-ray registers (where

they exist in paper

format)

30 years

Likely to have

archival value.

See note 1

S

X-ray reports

(including reports for

all imaging modalities)

To be considered as a permanent part of the patient

record and should be retained for the appropriate period

of time

S

Based on Royal College guidance


Page 90 of 133

Addendum 1: 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

United Kingdom Central Council for Nursing, Midwifery and Health Visiting

Joint Position on the Retention of 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 authority 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.

List of Maternity Records to be Retained

6. Maternity Records retained should include the following:

6.1 documents recording booking data and pre-pregnancy records where appropriate;

6.2 documentation recording subsequent antenatal visits and examinations;

6.3 antenatal in-patient records;

6.4 clinical test results including ultrasonic scans, alpha-feto protein and chorionic villus

sampling;

6.5 blood test reports;

6.6 all intrapartum records to include, initial assessment, partograph and associated records

including cardiotocographs;


Page 91 of 133

6.7 drug prescription and administration records;

6.8 postnatal records including documents relating to the care of mother and baby, in both

the hospital and community settings.


Page 92 of 133

Appendix H: Business and Corporate (Non-Health) Records Retention

Schedule

This retention schedule details a Minimum Retention Period for each type of non-health record.

Records (whatever the media) may be retained for longer than the minimum period. However,

records should not ordinarily be retained for more than 30 years. The National Archives (see Note

1 below) should be consulted where a longer period than 30 years is required, or for any pre-1948

records. Organisations should also remember that records containing personal information are

subject to the Data Protection Act 1998.

The following types of record are covered by this retention schedule (regardless of the media on

which they are held, including paper, electronic, images and sound):

administrative records (including personnel, estates, financial and accounting

records, and notes associated with complaint handling);

photographs, slides and other images (non-clinical);

microform (ie microfiche/microfilm);

audio and video tapes, cassettes, CD-ROMs, etc;

e-mails;

computerised records; and

scanned documents

The schedule is split into the following types of records:

Administrative (corporate and organisation)

Biomedical Engineering

Estates/engineering

Financial

IM & T

Other

Personnel/human resources

Purchasing/supplies

If viewed in electronic format, the search facility in Word or PDF can be used to search for

particular record types.

Notes

An organisation with an existing relationship with an approved Place of Deposit should consult the

Place of Deposit in the first instance. Where there is no pre-existing relationship with a Place of

Deposit, organisations should consult The National Archives.


Page 93 of 133

TYPE/SUBTYPE OF RECORD MINIMUM RETENTION PERIOD DERIVATION FINAL ACTION CODE

ADMINISTRATIVE (CORPORATE AND

ORGANISATION)

Accident forms (see also Litigation dossiers)

10 years

Destroy under

confidential

conditions

S

Accident register (Reporting of

Injuries,Diseases and Dangerous

Occurrencesregister) – see also Incident

forms

10 years

Reporting of Injuries,

Diseases and Dangerous

Occurrences Regulations

(reg. 7); Social Security

(Claims and Payments)

Regulations (reg. 25)

Destroy under

confidential

conditions

C

Adoption records

(i.e. administrative records relating 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 18th birthday

Children and Young Persons

Arrangements for Placement

of Children (General)

(Regulations 1991,SI 1991,

No. 890 regs. 8, 9, 10 –

children’s records) Adoption

Regulations 2004(reg. 34)

Destroy under

confidential

conditions

N

Advance letters (eg DH guidance)

6 years

Destroy

S

Agendas of board meetings, committees, 30 years See note 1 S


Page 94 of 133


sub-committees (master copies, including

associated papers)

Agendas (other)

2 years

Destroy under

confidential

conditions

S

Agreements (see Contracts)

Ambulance Records – Administrative (i.e.

records containing non-clinical details only)

e.g. records of journeys

2 years from the end of the year to

which they relate

Destroy under

confidential

conditions

N

Annual/corporate reports

3 years

See note 1

S

Appointment Records (GP)

2 years (Provided that any patient-

relevant information has been

transferred to the patient record)

At the end of the 2 year retention

period GP practices should consider if

there is an on-going administrative

need to keep the records/books for

longer. If there IS an ongoing need to

retain these records/books, then a

further review date should be set

Destroy under

confidential

conditions –

once a decision

has been made

that there is no

ongoing

administrative

need to retain

the records.

N


Page 95 of 133


(either 1 or 2 more years)

Assembly/Parliamentary questions, MP

enquiries

10 years

As these

documents

include all

information

provided by the

organisation in

response to a

PQ (e.g.

background note

to the Minister or

the Minster may

amend the

response) all of

which may not be

used in the

response and

therefore it will

not be in the

public domain on

House of

Commons

records they

must be

destroyed under

confidential

conditions.

S

Audit Records (e.g. Organisational Audits,

Records Audits, Systems Audits) – Internal &

2 years from the date of completion of

the audit

Destroy under

confidential

N


Page 96 of 133


External in any format (paper, electronic etc)

conditions

Business plans, including local delivery plans

20 years

Destroy

S

Catering forms

6 years

Destroy under

confidential

conditions

S

Close circuit TV images

31 days

Information Commissioner’s

Code of Conduct

Erase

permanently

S

Commissioning decisions

Appeal documentation

Decision documentation

6 years from date of appeal decision

6 years from date of decision

Destroy under

confidential

conditions

S

S

Complaints (See also litigation dossiers)

Correspondence, investigation and outcomes

Returns made to DH

8 years from completion of action

Files closed annually and kept for

6 years following closure

NB: Current policy on the handling of

complaints is under review and further

guidance will be issued in due course

Destroy under

confidential

conditions

C


Page 97 of 133


Copyright declaration forms

(Library Service)

6 years

Copyright, Designs and

Patents Act 1988

Destroy under

confidential

conditions

N

Data Input Forms (where the data/information

has been input to a computer system)

2 years

Destroy under

confidential

conditions

N

Diaries (office)

1 year after the end of the calendar

year to which they refer

Destroy under

confidential

conditions

S

Exposure monitoring records

5 years from the date the record was

made

Control of Substances

Hazardous to Health

Regulations 2002 (reg. 10(5))

Destroy under

confidential

conditions

S

’Find-a-Doc’ records (kept by PCT’s)

contact sheets and letters

assignment cases/letters

records of negotiations with GMS contract

managers re: patient registration with a

GP

6 months

2 years

2 years

Destroy under

confidential

conditions

N

Flexi working hours (personal record of hours

actually worked)

6 months

Destroy under

confidential

S


Page 98 of 133


conditions

Freedom of Information requests

3 years after full disclosure;

10 years if information is redacted or

the information requested is not

disclosed

Destroy under

confidential

conditions

S

GMS1 forms (registration with GP)

3 years

Destroy under

confidential

conditions

S

Health and safety documentation

3 years

Destroy under

confidential

conditions

S

History of organisation or predecessors, its

organisation and procedures (eg

establishment order)

30 years

See note 1

S

Hospital (trust) services

i.e. service that the Trust provides

e.g. catering, hotel services

10 years

Destroy

S

Incident forms

10 years

Destroy under

confidential

conditions

C


Page 99 of 133


Indices (records management)

Registry lists of public records marked

for permanent preservation, or

containing the record of management

of public records – 30 years

File lists and document lists where

public records or their management

are not covered – 30 years

See note 1

Destroy under

confidential

conditions

S

S

Laundry lists and receipts

2 years from completion of audit

Destroy under

confidential

conditions

S

Library registration forms

2 years after registration

Destroy

S

Litigation dossiers (complaints including

accident/incident reports)

Records/documents relating to any form of

litigation

10 years

Where a legal action has commenced,

keep as advised by legal

representatives

Destroy under

confidential

conditions

S

S

Manuals – policy and procedure

(administrative and clinical, strategy

documents)

10 years after life of the system (or

superseded) to which the policies or

procedures refer

Destroy (policy

documents may

have archival

value – see note

1)

S


Page 100 of 133


Maps

Lifetime of the organisation

See note 1

S

Meetings and minutes papers of major

committees and sub-committees

(master copies)

30 years

See note 1

S

Meetings and minutes papers (other,

including reference copies of major

committees)

2 years

Destroy under

confidential

conditions

S

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. There

may, however, be exceptions, such as

where they are required to be kept as

evidence in actual or expected

litigation or where they are needed by

a healthcare professional in order to

provide healthcare.

Each healthcare practitioner has

discretion as to the information which

s/he wishes to include as part of a

patient record. If in any particular case

a healthcare practitioner requires a

document which forms part of the

mental health act administration

record to be included in a patient’s

HC(91)29 (NHS)

SI 2001/3869, reg.47

(Independent Sector)

Destroy under

confidential

conditions

N


Page 101 of 133


record (because he or she regards it

as relevant to the patient’s

healthcare), it should then be

regarded as part of the patient’ health

record

Mortgage documents (acquisition, transfer

and disposal)

6 years after repayment

See note 1

S

Nominal rolls

6 years (maximum)

Destroy under

confidential

conditions

S

Papers of minor or short-lived importance not

covered elsewhere, eg:

advertising matter

covering letters

reminders

letters making appointments

anonymous or unintelligible letters

drafts

duplicates of documents known to be

preserved elsewhere (unless they have

important minutes on them)

indices and registers compiled for temporary

purposes

2 years after the settlement of the

matter to which they relate

Destroy under

confidential

conditions

S


Page 102 of 133


routine reports

punched cards

other documents that have ceased to be of

value on settlement of the matter involved

Patient Advice & Liaison Service (PALS)

records

10 years after closure of the case

Destroy under

confidential

conditions

N

Patient information leaflets

6 years after the leaflet has been

superseded

See note 1

C

Patients’ property books/registers (property

handed in for safekeeping)

6 years after the end of the financial

year in which the property was

disposed of or 6 years after the

register was closed

Destroy under

confidential

conditions

S

Patient Surveys (re access to services etc)

2 years

Destroy under

confidential

conditions

N

Phone Message Books

2 years

NB Any clinical information should be

transferred to the patient health record

Destroy under

confidential

conditions

N


Page 103 of 133


Police Statements (made in the context of

Accident and Emergency episodes.

Statements are requested by the Police to the

A&E staff in relation to alleged injuries of or

by patients coming through A&E)

10 years (congruent retention period

as Incident Forms)

Destroy under

confidential

conditions

N

Press cuttings

1 year

Destroy (where

bound volumes

exist, see note 1)

S

Press Releases

7 years

see note 1

N

Project files (over £100,000) on termination,

including abandoned or deferred projects

6 years

See note 1

S

Project files (less than £100,000) on

termination

2 years

Destroy under

confidential

conditions

S

Project team files (summary retained)

3 years

Destroy under

confidential

conditions

S

Public Consultations e.g. about future 5 years Destroy under N


Page 104 of 133


provision of services

confidential

conditions

Quality and Outcomes Framework (QOF)

documents (GP Practice records)

2 years

Destroy under

confidential

conditions

N

Quality assurance records (eg Healthcare

Commission, Audit Commission, King’s Fund

Organisational Audit, Investors in People)

12 years

Destroy under

confidential

conditions

S

Receipts for registered and recorded mail

2 years following the end of the

financial year to which they relate

Destroy under

confidential

conditions

S

Records documenting the archiving, transfer

to public records archive or destruction of

records

30 years

See note 1

S

Records of custody and transfer of keys

2 years after last entry

Destroy under

confidential

conditions

S

Reports (major) 30 years See note 1 S


Page 105 of 133


Requests for access to records, other than

Freedom of Information or subject access

requests

6 years after last action

Destroy under

confidential

conditions

S

Requisitions

18 months

Destroy under

confidential

conditions

S

Research ethics committee records

3 years from date of decision

See note 1

C

Serious incident files

30 years

See note 1

S

Specifications (eg equipment, services)

6 years

Limitation Act 1980

Destroy under

confidential

conditions

S

Statistics (including Korner returns, contract

minimum data set, statistical returns to DH,

patient activity)

3 years from date of submission

Destroy

S

Subject access requests (DPA and AHR)– 3 years after last action Destroy under

confidential

S


Page 106 of 133


records of requests

conditions

Surgical appliances forms AP 1, 2, 3 and 4


Destroy under

confidential

conditions

S

Time sheets (relating to a Group or

Department e.g. Ward where the timesheets

are kept as a tool to manage resources,

staffing levels)

6 months

Destroy under

confidential

conditions

N

BIOMEDICAL ENGINEERING

Sterilix Endoscopic Disinfector Daily Water

Cycle Test,

11 years

Consumer Protection Act

1987

Destroy under

confidential

conditions

N

Sterilix Endoscopic Disinfector Daily Water

Purge Test, Nynhydrin Test

11 years


1987

Destroy under

confidential

conditions

N

ESTATES/ENGINEERING


Page 107 of 133


Buildings and engineering works, including

major projects abandoned or deferred – key

records (eg final accounts, surveys, site

plans, bills of quantities)

30 years

See note 1

S

Buildings and engineering works, including

major projects abandoned or deferred – town

and country planning matters and all formal

contract documents (eg executed

agreements, conditions of contract,

specifications, ’as built’ record drawings,

documents on the appointment and

conditions of engagement of private buildings

and engineering consultants)

30 years

See note 1

S

Buildings – papers relating to occupation of

the building (but not health and safety

information)

3 years after occupation ceases

Construction Design

Management Regulations

1994

Destroy under

confidential

conditions

S

Deeds of title

Retain while the 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

See note 1

S


Page 108 of 133


Drawings – plans and buildings (architect

signed, not copies)

Lifetime of the building to which they

relate

See note 1

S

Engineering works – plans and building

records

Lifetime of the building to which they

relate

See note 1

S

Equipment – records of non-fixed equipment,

including specification, test records,

maintenance records and logs

11 years

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


1987

Destroy under

confidential

conditions

N

Inspection reports (eg boilers, lifts)

Lifetime of installation

If there is any measurable risk of a

liability in respect of installations

beyond their operational lives, the

records should be retained indefinitely

See note 1

S

Inventories of furniture, medical and surgical

equipment not held on store charge and with

a minimum life of 5 years

Keep until next inventory

See note 1

C

Inventories of plant and permanent or fixed

equipment

5 years after date of inventory

See note 1

S


Page 109 of 133


Land surveys/registers

30 years

See note 1

S

Leases – the grant of leases, licences and

other rights over property

Period of the lease plus 12 years

Limitation Act 1980

Destroy under

confidential

conditions

S

Maintenance contracts (routine)

6 years from end of contract

Destroy under

confidential

conditions

S

Manuals (operating)

Lifetime of equipment

Review if issues

(eg HSE) are

outstanding

S

Medical device alerts

Retain until updated or withdrawn

(check MHRA website)

www.mhra.gov.uk

Destroy under

confidential

conditions

S

Photographs of buildings

30 years

See note 1

S

Plans – building (as built)

Lifetime of building

May have

historical value –

see note 1

S


Page 110 of 133


Plans – building (detailed)


May have

historical value

(see note 1)

S

Plans – engineering


See note 1

S

Property acquisitions dossiers

30 years

See note 1

S

Property disposal dossiers

30 years

See note 1

S

Radioactive waste

30 years

Radioactive Substances Act

1993

See note 1

S

Site files

Lifetime of site

See note 1

S

Structure plans (organisational charts) i.e. the

structure of the building plans


See note 1

C

Surveys – building and engineering works

Lifetime of building or installation

See note 1

S


Page 111 of 133


FINANCIAL

Accounts – annual (final – one set only)

30 years

See note 1

S

Accounts – minor records (pass books,

paying-in slips, cheque counterfoils,

cancelled/discharged cheques (for cheques

bearing printed receipts, see Receipts),

accounts of petty cash expenditure, travel

and subsistence accounts, minor vouchers,

duplicate receipt books, income records,

laundry lists and receipts)


Destroy under

confidential

conditions

S

Accounts – working papers


Destroy under

confidential

conditions

S

Advice notes (payment)

1.5 years

Destroy under

confidential

conditions

S

Audit records (internal and external audit) –

original documents


Destroy under

confidential

conditions

N


Page 112 of 133


Audit reports – internal and external

(including management letters, value for

money reports and system/final accounts

memoranda)

2 years after formal completion by

statutory auditor

Destroy under

confidential

conditions

N

Bank statements


Destroy under

confidential

conditions

S

Banks Automated Clearing System (BACS)

records

6 years after year end

Destroy under

confidential

conditions

S

Benefactions (records of)

5 years after end of financial year in

which the trust monies become finally

spent or the gift in kind is accepted. In

cases where the Benefaction

Endowment Trust fund/capital/interest

remains permanent, records should

be permanently retained by the

organisation

See note 1

S

Bills, receipts and cleared cheques

6 years

Destroy under

confidential

conditions

S


Page 113 of 133


Budgets (including working papers, reports,

virements and journals)


Destroy under

confidential

conditions

S

Capital charges data


Destroy under

confidential

conditions

S

Capital paid invoices (see Invoices)

Cash books

6 years after end of financial year to

which they relate

Limitation Act 1980

Destroy under

confidential

conditions

S

Cash sheets


which they relate

Limitation Act 1980

Destroy under

confidential

conditions

S

Contracts – financial

Approval files – 15 years

Approved suppliers lists – 11 years

Destroy under

confidential

conditions

C

Contracts – non-sealed (property) on

termination

6 years after termination of contract Limitation Act 1980 Destroy under

confidential

S


Page 114 of 133


conditions

Contracts – non-sealed (other) on termination

6 years after termination of contract

Limitation Act 1980

Destroy under

confidential

conditions

S

Contracts – sealed (and associated records)

Minimum of 15 years, after which they

should be reviewed

See note 1

S

Contractual arrangements with hospitals or

other bodies outside the NHS, including

papers relating to financial settlements made

under the contract (eg waiting list initiative,

private finance initiative)


which they relate

Destroy under

confidential

conditions

S

Cost accounts


which they relate

Destroy under

confidential

conditions

S

Creditor payments


which they relate

Destroy under

confidential

conditions

S

Debtors’ records – cleared 2 years from completion of audit Destroy under S


Page 115 of 133


confidential

conditions

Debtors’ records – uncleared


Destroy under

confidential

conditions

S

Demand notes


which they relate

Destroy under

confidential

conditions

S

Estimates, including supporting calculations

and statistics


which they relate

Destroy under

confidential

conditions

S

Excess fares


which they relate

Destroy under

confidential

conditions

S

Expense claims, including travel and

subsistence claims, and claims and

authorisations


which they relate

Destroy under

confidential

conditions

S

Fraud case files/investigations 6 years Destroy under S


Page 116 of 133


confidential

conditions

Fraud national proactive exercises

3 years

Destroy under

confidential

conditions

S

Funding data


which they relate

Destroy under

confidential

conditions

S

General Medical Services payments


Destroy under

confidential

conditions

S

Invoices


which they relate

Limitation Act 1980

Destroy under

confidential

conditions

S

Ledgers, including cash books, ledgers,

income and expenditure journals, nominal

rolls, non-exchequer funds records (patient

monies)


which they relate

Limitation Act 1980

Destroy under

confidential

conditions

S


Page 117 of 133


Non-exchequer funds records (i.e. funding

received by the organisation that does not

directly relate to patient care eg charitable

funds)

30 years

Company charities are required by

company law to keep their accounts

and accounting records for at least

three years but the Charity

Commission recommends that they

be kept for at least 6 years. The

majority of non-company charities

must keep their accounts and

accounting records for six years (Part

VI Charities Act 1993).

Although

technically

exempt from the

Public Records

Act, it would be

appropriate for

authorities to

treat these

records as if they

were not exempt

N

Patient Monies (i.e. smaller sums of donated

money)

6 years

Destroy under

confidential

conditions

N

PAYE records

6 years after termination of

employment

Destroy under

confidential

conditions

S

Payments


Destroy under

confidential

conditions

S

Payroll (ie list of staff in the pay of the

organisation)

6 years after termination of

employment

Destroy under

confidential

conditions

S


Page 118 of 133


For

superannuation

purposes,

organisations

may wish to

retain such

records until the

subject reaches

benefit age

Positive predictive value performance

indicators

3 years

Destroy under

confidential

conditions

S

Private Finance Initiative (PFI)

30 years

See note 1

S

Receipts


which they relate

Limitation Act 1980

Destroy under

confidential

conditions

S

Salaries (see Wages)

Superannuation accounts

10 years

Destroy under

confidential

conditions

S


Page 119 of 133


Superannuation registers

10 years

Destroy under

confidential

conditions

S

Tax forms

6 years

Destroy under

confidential

conditions

S

Transport (staff pool car documentation)

3 years unless litigation ensues

Destroy under

confidential

conditions

S

Trust documents without permanent

relevance/not otherwise mentioned

6 years

Destroy under

confidential

conditions

S

Trusts administered by Strategic Health

Authorities (terms of)

30 years

See note 1

S

VAT records


which they relate

Destroy under

confidential

conditions

S

Wages/salary records 10 years after termination of Destroy under S


Page 120 of 133


employment

confidential

conditions

For

superannuation

purposes,

organisations

may wish to

retain such

records until the

subject reaches

benefit age.

IM & T

Documentation relating to computer

programmes written in-house

Lifetime of software

Destroy under

confidential

conditions

S

Software licences

Lifetime of software

Destroy under

confidential

conditions

S

OTHER

Chaplaincy records

2 years

May have

archival value –

S


Page 121 of 133


see note 1

Contractor Applications (Doctors, Dentists,

Opticians & Pharmacists)

6 years after end of contract for

approvals

6 years for non-approvals.

Destroy under

confidential

conditions

N

Contractor Records

(e.g. 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 seven

years, and shall during that

period produce them when

required to do so by a Primary

Care Trust or the Secretary of

State.

Follow link below for more

detail

http://www.dh.gov.uk/assetRo

ot/04/10/12/ 42/04101242.pdf

Destroy under

confidential

conditions

N

Doctors Postgraduate Educational Allowance/ GP Seniority (prior to 2004 – new NHS(General Ophthalmic Destroy under N


Page 122 of 133


Personal Development Plan files and

supporting general correspondence –

Records kept by PCT’s

regulations)

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 seven

years, and shall during that

period produce them when

required to do so by a Primary

Care Trust or the Secretary of

State.

Follow link below for more

detail


ot/04/10/12/ 42/04101242.pdf

confidential

conditions

Family Health Service Appeals Authority

tribunal and case files

Case files – 10 years

Decision records – until individual’s

80th birthday

See note 1

Destroy under

confidential

conditions

S

GP retirements/moved away

6 years after individual leaves service,

at which time a summary of the file

must be kept until the individual’s 70th

birthday

See note 1

N


Page 123 of 133


Research and development (organisation)

i.e. all the organisation’s records associated

with research and development and not

individual trial records or information on

patients.

30 years

Medical Research Council

See note 1

N

PERSONNEL/HUMAN RESOURCES

NB Both medical staff records and agency

locums staff records should be treated as

personnel records and retained accordingly.

Consultants (records relating to the

recruitment of)

5 years

NHS (Appointment of

Consultants) Regulations,

good practice guidelines, page

11, para. 5.3


ot/04/10/27/ 50/04102750.pdf

Destroy under

confidential

conditions

S

CVs for non-executive directors (successful

applicants)

5 years following term of office

Destroy under

confidential

conditions

S

CVs for non-executive directors

(unsuccessful applicants)

2 years

Destroy under

confidential

conditions

S


Page 124 of 133


Duty rosters

i.e. organisation or departmental rosters, not

the ones held on the individual’s record.

4 years after the year to which they

relate

Destroy under

confidential

conditions

N

Industrial relations (not routine staff matters),

including industrial tribunals

10 years

Destroy under

confidential

conditions

S

Job advertisements

1 year

Destroy

S

Job applications (successful)

3 years following termination of

employment

Destroy under

confidential

conditions

S

Job applications (unsuccessful)

1 year

Destroy under

confidential

conditions

S

Job descriptions

3 years

Destroy under

confidential

conditions

S

Leavers’ dossiers 6 years after individual has left

Summary to be retained until

The 6 year retention period is

to take into account any ET

Destroy under

confidential

N


Page 125 of 133


individual’s 70th birthday or until 6

years after cessation of employment if

aged over 70 years at the time.

The summary should contain

everything except attendance books,

annual leave records, duty rosters,

clock cards, timesheets, study leave

applications, training plans

claims, or EL claims that may

arise after the employee

leaves NHS employment,

requests for information from

the NHS pensions agency etc.

Claims of this nature can

include periods of up to 6

years or more prior to the

claim and where evidence

could be needed from a

number of sources, it is

appropriate to retain as

much as possible from the

original file.

conditions

See note 1

Letters of appointment

6 years after employment has

terminated or until 70th birthday,

whichever is later

Destroy under

confidential

conditions

S

Nurse training records (from hospital-based

nurse training schools prior to the introduction

of academic-based training)

30 years

See note 1

N

Pension Forms (all)

7 years

HMRC Technical Pension

Notes for registered pension

schemes under regulation 18

of SI2006/567 –

‘RPSM12300020 – Scheme

Destroy under

confidential

conditions

N


Page 126 of 133


Administrator Information

Requirements and

Administration for General

Retention of Records’

Personnel/human resources records –major

(eg personal files, letters of appointment,

contracts, references and related

correspondence, registration authority forms,

training records, equal opportunity monitoring

forms (if retained))

NB Includes locum doctors

6 years after individual leaves service,

at which time a summary of the file

must be kept until the individual’s 70th

birthday

Summary to be retained until

individual’s 70th birthday or until 6

years after cessation of employment if

aged over 70 years at the time.

The summary should contain

everything except attendance books,

annual leave records, duty rosters,

clock cards, timesheets, study leave

applications, training plans

The 6 year retention period is

to take into account any ET

claims, or EL claims that may

arise after the employee

leaves NHS employment,

requests for information from

the NHS pensions agency etc.

Claims of this nature can

include periods of up to 6

years or more prior to the

claim and where evidence

could be needed from a

number of sources, it is

appropriate to retain as

much as possible from the

original file.

See note 1

N

Personnel/human resources records – minor

(eg attendance books, annual leave records,

duty rosters (i.e. duty rosters held on the

individual’s record not the organisation or

departmental rosters), clock cards,

timesheets (relating to individual staff

members))


relate

Destroy under

confidential

conditions

N


Page 127 of 133


NB Includes locum doctors

Staff car parking permits

3 years

Destroy under

confidential

conditions

S

Study leave applications

5 years

Destroy under

confidential

conditions

S

Timesheets (for individual members of staff)


relate

NB Timesheets (for all individuals

including locum doctors) held on the

personnel record are minor records –

retain for 2 years.

Timesheets held elsewhere – i.e. on

the ward retain for 6 months (as the

master timesheet is held on the

personnel file)

Destroy under

confidential

conditions

N

Training plans

2 years

Destroy under

confidential

conditions

S

PURCHASING/SUPPLIES


Page 128 of 133


Approval files (contracts)

6 years after end of the year the

contract expired

Destroy under

confidential

conditions

S

Approved suppliers lists

11 years


1987

Destroy under

confidential

conditions

S

Delivery notes


which they relate

Destroy under

confidential

conditions

S

Products (liability)

11 years


1987

Destroy under

confidential

conditions

S

Stock control reports

18 months

Destroy under

confidential

conditions

S

Stores records – major (eg stores ledgers)

6 years

Destroy under

confidential

conditions

S


Page 129 of 133


Stores records – minor (eg requisitions, issue

notes, transfer vouchers, goods received

books)

18 months

Destroy under

confidential

conditions

S

Supplies records – minor (eg invitations to

tender and inadmissible tenders, routine

papers relating to catering and demands for

furniture, equipment, stationery and other

supplies)

18 months

Destroy under

confidential

conditions

S

Tenders (successful)

Tender period plus 6 year limitation

period

Limitation Act 1980

Destroy under

confidential

conditions

S

Tenders (unsuccessful)

6 years

Limitation Act 1980

Destroy under

confidential

conditions

S

Bolton Hospitals NHS Trust Records Management Strategy

130

Annex : 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 issue 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/PolicyandGuidance/OrganisationPolicy/RecordsManagement/

In the meantime, NHS organisations are advised to retain all audit trails until

further notice.


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Equality Impact Assessment Initial Screening Tool

This Initial Screening Tool is the first step in completing an Equality Impact Assessment (EIA) of your ‘activity’ (strategies, functions, policies, procedures, projects, services etc). Once this is completed, it will be apparent whether or not a full EIA is required.

This proforma should be used in conjunction with the EIA Guidance available on the Trust’s intranet website under A-Z Services, using the Equality & Diversity link, where you will also find links to the Trust’s Single Equality Human Rights Scheme (SEHRS).


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12. If the actions in 11 above are completed (answer Yes or No) revisit section 12 when action in 11 complete

Age

Dis

abili

ty

Gender

Race

Relig

ion/B

elie

f

Language

Sexual

Orie

nta

tio

n

Gypsy/r

om

a

Tra

velle

r

Care

rs

Em

plo

yees

Ne

g

ative

Imp

act 1. Will the activity present any

problems or barriers to any community or group?

No No No No No No No No

No no

1. Directorate Strategy and Improvement

2. Department IT Services

3. Name of ‘activity’ being assessed Records Management Policy

4. Person completing this form Graham Fullarton

5. Date 8th January 2015

6. Monitoring data/statistics – compare ‘activity’ data with ‘population’ data (see Guidance)

Patients

Staff

Equality Target Groups (ETGs) (See guidance for detail)

7. Which of the following Equality Target Groups will this ‘activity’ impact

on?

8. Could this ‘activity’ have a positive and/or

negative impact?

yes no Positive* Negative*

A. Age x

B. Disability x

C. Gender x

D. Race x

E. Religion/Belief x

F. Language x

G. Sexual Orientation x

H. Gypsy/Roma/Traveller x

I. Carers x

J. Employees x

9. Consultation/Involvement – during the development of this activity? (see Guidance)

IM&T Committee, Information Governance Group, Executive Board, Consultant staff, other staff nominated by Divisions

10. Details of positive and negative impacts

Positive Impacts Promotion of patient privacy and confidentiality in accordance with individual rights under the Data Protection Act and Human Rights Act (article 8) Negative Impacts

11. Give details of actions required to remedy any negative impact(s) identified above.

Action to address negative impact Who Target Date


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2. Will any group of people be

excluded as a result of your activity? No No No No No No No No

No no

3. Does the activity have the potential

to worsen existing discrimination and inequality?

No No No No No No No

No

No no

4. Will the activity have a negative

effect on community relations? No No No No No No No No

No no

Positiv

e im

pact

Could the activity reduce inequalities? Will it… (answer Yes or No)

Age

Dis

abili

ty

Gender

Race

Relig

ion/

Belie

f

Language

Sexual

Orie

nta

tio

n

Gypsy/r

om

a

Tra

velle

r

Care

rs

Em

plo

yees

5. Promote equality of opportunity? X X X X X X X X X x

6. Eliminate discrimination? X X X X X X X X X x

7. Eliminate harassment? X X X X X X X X X x

8. Promote good community

relations? X X X X X X X

X X x

9. Promote positive attitudes towards disabled people? X X X X X X X

X X x

10. Encourage the participation of disabled people? X X X X X X X

X X x

11. Consider more favourable

treatment of disabled people? X X X X X X X X

X x

12. Promote and protect human

rights? √ √ √ √ √ √ √ √

√ √

Thank you for completing this EIA initial screening tool.

Please forward an electronic copy of the completed tool to your Divisional E&D Lead for ratification by your

Divisional Board and a copy to: Suzanne Hudson Email: [email protected] Telephone extension: 4017

Decision

Work through the flowchart on page 24 of the Guidance, to determine whether you need to complete a Full EIA or not. Details of any objective justifications or amendments agreed with Divisional E&D Lead: Full EIA required? Yes No x Date approved by Divisional Boards:

Completed by: graham Fullarton Job Title: Information Governance Bolton NHS

Foundation Trust ce Manager

mailto:[email protected]