IG14 46.1 Health Records Management Procedure Health Records... · divider. • Never use a stapler to attach information to the casenote folder as this can tear and weaken the case

Betsi Cadwaladr University Health Board IGC Item IG14/46.1

Subject: HR1 Health Records Management Procedure Summary or Issues of Significance

This procedure defines the BCUHB Creation, Maintenance, Retention & Destruction Periods for Health records and highlights requirements to select records for permanent preservation. This will support the confidentiality, integrity and availability of all information held and/or used by the BCUHB.

Strategic Theme / Priority / Values addressed by this paper

Making it safe / better / sound / work / happen This procedure aims to ensure that all records are; designed, prepared, reviewed & accessible to meet the required needs; stored safely, maintained securely, are retrievable in a timely manner and disposed of appropriately; accurate, complete, understandable and contemporaneous in accordance with professional standards and guidance; and shared as appropriate.

Equality Impact Assessment (EqIA)

Has EqIA screening been undertaken? Yes

Recommendations: This procedure has been reviewed and updated and requires

consultation and approval by the Information Governance Committee.

Author(s) L. Pritchard, N. Harrison, K. Ratcliffe, E. Thomas and L. Jones

Presented by Dylan Williams Date of report 13.05.14 Date of meeting 14.7.14

HR1

HEALTH RECORDS MANAGEMENT PROCEDURE (INCLUDING RETENTION & DESTRUCTION SCHEDULE) Date to be reviewed: May 2015 No of pages: 17 Author(s): Nia Harrison

Lynda Pritchard Kate Ratcliffe Eirian Thomas Lisa Jones

Author(s) title:

Health Records Managers PA to Nia Harrison

Responsible dept / director:

Health Records Department/Informatics

Approved by: Health Records Group and Information Governance Committee Date approved: June 2012 Endorsement by: Health Records Group and Information Governance Committee Date endorsed: June 2012 Date activated (live): June 2012

Date EQIA completed: November 2011 Documents to be read alongside this procedure:

Records Management Policy Corporate Records Management Procedure Informatics Strategy Guidelines for Safe Filing & Retrieval of Casenotes, including use of Mobile Racking & Access Equipment Sharing Acute Health Records Procedure

Review A

Purpose of Issue/Description of current changes: New procedure for Betsi Cadwaladr University Health Board

First operational: June 2012 Previously reviewed: May-14 date date date date

Changes made yes/no: Yes Yes/no Yes/no Yes/no Yes/no

PROPRIETARY INFORMATION

This document contains proprietary information belonging to the Betsi Cadwaladr University Health Board. Do not produce all or any part of this document without written

permission from the BCUHB.

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C O N T E N T S

1. Introduction &Procedure Statement

2. Scope

3. Definition of Health Record

4. Aims & Objectives

5. Roles & Responsibilities

5.1 Chief Executive 5.2 The Director of Governance and Communications 5.3 Caldicott Guardian 5.4 Information Governance (IG) Committee 5.5 Health Records Group 5.6 Health Records Managers 5.7 Clinical Programme Group/Corporate Function Managers 5.8 All Staff

6. Standards of Record Keeping

6.1 Good Record Keeping Principles 6.2 Inclusion of an Alert Divider

7. Computerised Records

8. Monitoring & Audit

9. Confidentiality& Data Protection

10. Health Records Life Cycle

10.1 Creation 10.2 Storage & Security 10.3 Casenote Tracking 10.4 Transportation of Records 10.5 Maintenance 10.6 Retrieval 10.7 Retention &Destruction

11. Further Guidance

12. Reference to Legislation

Appendix A: Retention Periods for Acute Health Records

Appendix B: Retention Periods for GP Health Records

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1. Introduction and Procedure Statement

1.1 Betsi Cadwaladr University Health Board (BCUHB) is dependent on its records to operate efficiently and account for its actions. An effective records management system is critical in the provision of care to patients and to assist in the efficient running of the organisation.

1.2 This procedure defines the BCUHB Creation, Maintenance, Retention & Destruction Periods for Health records and highlights requirements to select records for permanent preservation. This will support the confidentiality, integrity and availability of all information held and/or used by the BCUHB.

2. Scope

2.1 This procedure and its associated procedures relate to all clinical records held in any format by BCUHB. These include:

• All patient health records (including deceased patient records, patient registers, etc.)

2.2 This procedure applies to all staff employed by or contracted to BCUHB and includes

experts who the BCUHB might call upon in consultation. 3. Definition of a Health record

A Health Record is a single record with a unique identifier containing information relating to the physical or mental health of a given patient who can be identified from that information and which has been recorded on, or on behalf of, a health professional, in connection with the care of the patient. This may comprise of text, sound, image and/or paper and must contain sufficient information to support diagnosis, justify the treatment and facilitate the on-going care of the patient to whom it refers.

4. Aims & Objectives

This procedure and its associated procedures aim to ensure that all records are: • Designed, prepared, reviewed & accessible to meet the required needs;

• Stored safely, maintained securely, are retrievable in a timely manner and disposed of appropriately;

• Accurate, complete, understandable and contemporaneous in accordance with professional standards and guidance; and

• Shared as appropriate

5. Responsibilities

5.1 Chief Executive

The Chief Executive has overall responsibility for records management within BCUHB. 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.

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Records management is key to this as it will ensure appropriate, accurate information is available as required.

5.2 The Director of Governance and Communications

The Director of Governance and Communications has a particular responsibility for ensuring that it corporately meets its legal responsibilities, and for the adoption of internal and external governance requirements.

5.3 Caldicott Guardian

The BCUHB’s Medical Director is the Caldicott Guardian and 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. 5.4 Information Governance (IG) Committee

The IG Committee is responsible for ensuring that this procedure is implemented, through the Records Management Strategy, and that the records management system and processes are developed, co-ordinated and monitored.

5.5 Health Records Group

The Health Records Group is a formal sub group of the BCUHB IG Committee and its purpose is to provide advice to the IG Committee with regard to the quality, integrity, safety, security, appropriate access and use of health records. To also provide assurance to the IG Committee in relation to safeguarding, disseminating, sharing, using and disposing of health records in accordance with legislative responsibilities.

5.6 Health Records Managers

The Health Records Managers are responsible for the overall management and performance of the Health Records Service within BCUHB including the provision of organisation-wide access to health records.

5.7 Clinical Programme Group/Corporate Function Managers

The responsibility for local records management is devolved to the relevant Directors within BCUHB, i.e. to ensure that records controlled within their CPG/ directorate are managed in a way which meets the aims of BCUHB’s records management policy and procedures.

5.8 All Staff

As an employee of the LHB, the post holder is legally responsible for all records that they gather, create or use as part of their work within the LHB (including patient health, financial, personal and administrative), whether paper based or on computer. All such records are considered public records, and the post holder has a legal duty of confidence to service users (even after an employee has left the LHB).

6. Standards of Record Keeping

Patient records should be a clear, accurate and contemporaneous record of the relevant clinical findings, the decisions made, planned care, the information given to the patient or any

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drugs or other treatment prescribed. Effective record keeping is a means of communicating with others. 6.1 Good Record Keeping Principles

• It is expected that all Healthcare Professionals will abide by the Standards of Record

Keeping set by their own Professional Body.

• All records must be in English in accordance with the BCUHB’s Working Language. These can be translated into Welsh by the Health Board’s team of translators if requested by the patient, and a copy kept in the patient’s files.

• All entries must be written legibly & indelibly. It is preferable that entries are made in black ink.

• Each entry must be accurately dated, timed & signed, followed by the printed or stamped name and details of designation.

• All individual documents within a record must be clearly identifiable including local identifier, patient name, date of birth, and NHS number, by ensuring an identification label is used, in case any documents become loose.

• Front Sheet should always be checked to ensure it is up to date prior to filing within the casenotes, behind the alert divider.

• All investigations must assessed and signed by the clinician prior to being filed within the casenotes and fixed firmly to the corresponding mount sheet i.e. microbiology, biochemistry etc.

• Consent forms must be completed and signed prior to being filed behind the appropriate divider.

• Never use a stapler to attach information to the casenote folder as this can tear and weaken the case note folder and may cause injuries to those handling the case notes. It may also result in documentation becoming loose and lost from the folder.

• Never use paperclips to attach information to the front of the case notes as this can easily be transferred to another set of case notes by accident.

• If there are plastic pockets on the front of the casenote folder, these should be used for non-confidential messages or to indicate that there is a message on the inside folder.

• Confidential messages should be placed in the plastic pocket on the inside of the front of the casenote folder. A message should be placed in the pocket on the front of the casenote, if available; to indicate that there is a message inside.

• Never write or deface the front of the casenote folder. Only a label, with the patient’s name and hospital number, should be included on the front cover. It is important that information within the casenotes is filed accurately and securely.

• Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order, behind the relevant divider within the casenotes.

• Child protection and safeguarding issues must always be filed behind the lilac safeguarding divider.

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6.2. Inclusion of an Alert Divider

• All casenotes are to contain a red Alert Divider at the front of the folder, ensuring there is no documentation obstruction it from view i.e. Patient Demographics sheet. If there is no alert divider, you must ensure that one is filed ready in the event of a possible alert.

• Lasting power of attorney, Advanced Decisions, Protection of Vulnerable Adults (POVA) and Parental Responsibility Documents must always be filed behind the Alert Divider at the front of the casenotes.

• Do not resuscitate forms (DNR) must be placed in the very front of the folder, on top of the Alert Divider.

• If Alert Information is contained within the folder and noted on the alert divider, a ‘STOP ALERT, LOOK INSIDE’ label must be placed on the the front cover to bring any alerts to the attention of clinical staff.

7. Computerised Records

With regard to the retention of records produced by computers the normal consideration will apply where printed statements and records are produced. Where the records are held only a microfilm, microfiche or original magnetic data files, the Department of Health recommends that they should be retained, using the same criteria governing the retention of more conventional records, but taking extra care to prevent corruption or deterioration of the data. Re-recording/migration of the data may also need to be considered as equipment and software becomes obsolete.

8. Monitoring & Audit

The Health Board will regularly audit records management systems and implement improvements ensuring all records are fit for purpose. As a minimum, teams will be required to participate in annual record keeping audit; however, each department will need to prioritise the frequency and quantity of activity in response to their baseline findings. More frequent activity will be required where recommendations to improve practice have been identified and to measure the success of the agreed action plan.

To ensure this the Health Board has developed a standardised audit pro-forma which focuses upon core items agreed by the Health Records Committee and based upon national guidance. These are available from the Clinical Audit Department in a data-capture format (FORMIC/TELEFORM) and may be tailored to integrate additional items of local interest/concern.

9. Confidentiality & Data Protection

The Health Board has a common law duty of confidence to patients as well as a duty to maintain professional ethical standards of confidentiality. Everyone who is employed by the Health Board must at all times be aware of the importance of maintaining confidentiality and security of information gained during the course of their duties. This will in many cases include access to personal information relating to service users. Everyone must treat all information whether corporate, staff or patient information in a discreet and confidential manner in accordance with the provisions of the data protection act 1998 and organisational policy.

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10. Health Records Life Cycle

10.1 Creation

All records created, designed or prepared must be ‘fit for purpose’

• A comprehensive health record is created and maintained for every patient attending health services to provide an up to date and chronological account of the patient’s care.

• Patient demographic data for each registration should be recorded on a patient administration system. The minimum patient demographic data should include: surname, forename, sex, date of birth, home address, postcode, patient’s first language and local identifier. The NHS number should also be included when available.

• Where there is more than one local identifier or case record per patient, a system should be in place to ensure that the existence of all other health records is known.

• The paper health record has a standard case record folder constructed of robust material which can withstand handling and transport and has secure anchorage points to protect against loss or damage to documentation.

• There is a locally agreed format for the filing of the information in the health record which facilitates ease of access to all clinical information.

• The Health Records Group is responsible for commissioning, considering and approving requests for changes to health records. Their approval MUST be sought to ensure that records are ‘fit for purpose’

10.2 Storage & Security

Records MUST be stored safely and maintained securely. • When a record is in constant use, wherever possible, it should be stored as near as

possible to where it is needed.

• All records must be stored in areas which are secure, have adequate fire protection and are not in significant danger of flooding.

• Use of microfiche or scanning is acceptable providing that it is done and stored to the appropriate industry standards and that technology used allows for future access.

• Computerised records must be password protected and only authorised staff should have access to the systems.

10.3 Casenote Tracking

The responsibility for tracking the journey of a set of health records lies with each and every member of staff who handles them.

• Once the decision has been made to create a health record it must be captured in an effective tracking system to ensure they can be located on request.

• Each set of casenotes that is created has an assigned volume number; the tracking function on the Patient Administration Systems identifies each casenote and volume associated with the patient.

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• The success of any tracking system depends on the people using it and therefore, all staff must be aware of its importance and provided with regular and appropriate training. Audit is used to highlight any issues that arise as a result of non-compliance.

• Before moving casenotes the tracking system must be updated with the new location. Under no circumstance should casenote be removed from a department without being tracked.

• The person who is sending the casenotes is responsible for updating the tracking screen. However, when casenotes are received the tracking should be checked to ensure accuracy.

• When sending a set of casenotes to an area which does not have a tracking code, the person who has the records must contact the Health Records Manager.

• Any area which does not have access to the computerised tracking system should notify the Library if they send a set of casenotes to another area so that the tracking system can be updated.

10.4 Transporting Health Records

Following tracking the casenotes on the Patient Administration system you must prepare them for transport ensuring:

• Casenotes are enclosed in sealed envelope and left in the relevant collection point for delivery.

• Larger quantities of casenotes must be transported in trolleys for health and safety reasons. Staff must also ensure that the casenotes are covered in the trolleys while being transported for confidentiality reasons.

• Scanned records transferred electronically must be undertaken in line with the BCUHB Internet/Intranet & Email Policies and the Code of Conduct Policy in respect of Confidentiality.

10.5 Maintenance

Maintaining the health record is vital to patient care. Maintenance of records must be carried out in a manner that effectively services the needs of the records users.

• The health records system has well defined procedures for the ongoing management of the health record from initiation to final disposal in accordance with legislation.

• Whenever possible, separate areas are maintained for active and inactive health records in use within the organization.

10.6 Retrieval

• It is important that records are only viewed by staff who have the authority to do so.

• Records must be stored in a manner that allows timely retrieval to suit BCUHB needs. • In order to ensure the safety of staff and to enable the correct use of mobile racking and

relevant equipment, please see the Safe Filing and Retrieval of Casenotes, including use of mobile racking and access equipment, for further guidance.

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10.7 Retention &Destruction

It is a fundamental requirement that all of the Health Board’s health records are maintained for a minimum period of time for clinical, legal, operational, research and safety reasons.

• The Health Board has adopted the minimum retention periods as set out in the retention

schedule (Appendix A). The Health Board retention schedule will be reviewed according to legislative or Welsh Government changes.

• The recommended minimum retention periods should be calculated from the end of the calendard or accounting year following the the last entry on the document.

• The destruction of eligible records is an irreversible act and it is therefore vital that no records should be destroyed without the appropriate authority from the relevant health professional body or Health Records Group and actions clearly minuted.

• The selection of files for permanent preservation is partly informed by precedent (the establishment of a continuity of selection) and partly by the historical context of the subject (the informed identification of a selection) in line with the Public Records Act 1958 (Please refer to Appendix A)

• Every care must be taken to ensure that sensitive and/or confidential information is protected and where large quantities of records are required to be destroyed an approved contractor should be used.

• All approved contractors are required to produce written certification as proof of destruction of all sensitive and/or confidential information.

11. Further Guidance

This Procedure and the schedule appended are intended to give guidance on how long records should be kept for business purposes and on the identification of records of permanent value. The retention periods noted are minimum retention periods only, and if clarification or further assistance is required the appropriate authority should be contacted.

To ensure compliance with this Procedure, all staff will be made aware of this procedure and its associated control documents through methods such as induction courses, Information Governance training, Good Record Keeping and adhoc tailored Good Record Keeping sessions.

12. Reference to Legislation

• Access To Health Records Act 1990

• BCUHB Access To Health Records Procedures & Supplementary Guidance (IG02)

• Caldicott Guidelines 1997

• All Wales Child Protection Procedures 2002 (amended 2008)

• Department of Health - NHS Code of Practice (NHS England Policy)

• Data Protection Act 1998

• For the Record – Managing Records in NHS Trust & Health Authorities WHC (2000) 71

• Freedom of Information Act 2000

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• BCUHB Procedure for compliance with the Freedom of Information Act 2000 & the Environmental Information Regulations 2004 (IG03)

• Guidance for Doctors on Record Keeping(GMC Management for Doctors, Keeping Records)

• Health & Safety At Work Act

• HICIW – Healthcare Standards

• Human Rights Act 1998

• Mental Capacity Act 2005

• Mental Health Code of Practice

• Preservation, Retention & Destruction of GP General Medical Services Records Relating to Patients WHC (1999)7

• Public Records Act 1958 (amended 1967)

• Protecting patient identifiable Information: Caldicott Guardians in the NHS WHC (99) 92

• BCUHB Records Management Policy (IG01)

• BCUHB’s Welsh Language Scheme and Welsh Language Act 1993

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Appendix A: NHS Retention & Disposal Schedule The criteria set out in this appendix are intended to give guidance on how long records should be kept for business purposes and on the identification of records of permanent value.

In each NHS Organisation, records managers must ensure that records no longer required for business are reviewed as soon as practicable under the criteria set out below so that ill-considered destruction is avoided. This schedule identifies minimum retention periods. Whenever the schedule is used, the guidelines listed below should be followed:-

• Local business requirements/instructions must be considered before activating retention periods in this schedule.

• Decisions should also be considered in the light of the need to preserve records, whose use cannot be anticipated fully at the present time, but which may be of value to future generations.

• Recommended minimum retention periods should be calculated from the end of the calendar or accounting year following the last entry on the document.

• Where the period of retention column is marked with an asterisk (*), the documents described must be considered for permanent preservation and the advice of the chief

archivist of an appropriate place of deposit* obtained.

• The selection of files for permanent preservation is partly informed by precedent (the establishment of a continuity of selection) and partly by the historical context of the subject (the informed identification of a selection). General rules should be drawn up locally, using the profile of material which has already been selected, and examples of excellence) within the context of its service to the local and wider communities.

• The provisions of the Data Protection Act 1998 must also be complied with.

• The Department of Health is considering a proposal to establish a national selection policy. This procedure could identify regions in which specialist records would have precedence in selection for permanent preservation because of a history of regional excellence or innovation in a particular discipline.

The schedule does not seek to cater for all eventualities: the responsible records managers need to consider whether exceptional circumstances require the long-term preservation of the records.

Records selected for permanent preservation should be transferred to the relevant place of deposit for public records, appointed by the Keeper of Public Records. In most cases the appropriate place of deposit is the nearest Local Authority Record Office, although in a few cases a hospital has been appointed as a place of deposit for its own records. *

Places of deposit for public records - In cases where there is any doubt about the most appropriate place of deposit, advice should be sought from the Archive Inspection Services, Public Record Office, KEW TW9 4DU.

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Record Type/Sub Type Retention

Period (Years)

Notes

Abortion - Certificate A (Form HSA1) and Certificate B (Emergency Abortion)

3 Abortion Regulations 1991, Statutory Instrument No. 499

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

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

Birth registers (i.e. register of births kept by the hospital)

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

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

Death registers (i.e. register of deaths kept by the hospital)


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


Diaries (i.e. Health visitors, district nurses & other clinical/professional staff)

2 After end of year to which diary relates. Patient relevant information should be transferred to patient record.

Health Records – personal/patients See Hospital patient case records

Hospital patient case records (individual)

N.B. This retention schedule does not cover GP health records. Guidance on their retention can be found in HSC 1998/217 and ECL 2/68, both of which remain current at the time of issue of this circular.

Any reference to “conclusion of treatment" in the following recommended minimum retention periods should be taken to include all follow-up checks and action in connection with the treatment.

The retention periods which are listed below, reflect minimum requirements of clinical need. Personal health records may be required as evidence in legal actions; the minimum retention periods take account of this requirement. It is not necessary to keep every piece of paper received in connection with patients. NHS Organisations and Health Authorities should determine, in consultation with their health professionals, which elements should be considered as a permanent part of the record, and which should be transient and discarded as their value ceases.

Before any destruction takes place, ensure that

(a) there is consultation with the relevant health professional body or records committee and actions clearly minuted;

(b) any other local clinical need is considered; and

(c) The value of the records for long-term research purposes has been assessed, in consultation with an appropriate place of deposit.

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Record Type/Sub Type Retention

Period (Years)

Notes

- Pre-1948 Records Should by now have been transferred for permanent preservation or destroyed. Any pre-1948 records which still exist should be considered for permanent preservation, undergoing an appraisal procedure as described in the box above.

- Children and young people Until the patient's 25th birthday, or 26th if young person was 17 at conclusion of treatment; or 8 years after patient's death if death occurred before 18th birthday.

- Continuing Healthcare Records 11 years after conclusion of treatment or death.

- Contraception & Sexual Health Records 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 & Disposal of Hospital Notes, British Association for Sexual Health and HIV (BASHH)

http://www.bashh.org/committees/cgc/servicesspec/guidanceretentiondisposalof notes0606.pdf

- Dental Records 11 years after conclusion of treatment for adults

For children 11 years or up to their 25th birthday, whichever is longer.

Dental Protection’s advice would be to adopt the period of time set out under the NHS Code for Community care as an absolute minimum (as above) and also advises that records that relate to complex treatment or particularly difficult patients should be kept for up to 30 years.

- Donor records 11 years post transplantation. Committee on Microbiological Safety of Blood and Tissues for Transplantation (MSBT); guidance issued in 1996.

Family Planning 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.

- 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 - see Appendix B2 for additional guidance on retention and storage of maternity records previously issued with WHC(94)23

- Mentally disordered persons (within the meaning of the Mental

Health Act 1983)

20 years after no further treatment considered necessary; or 8 years after the patient's death if patient died while still receiving treatment.

- Oncology 8 years after conclusion of treatment, especially when surgery only involved. Consideration may wish to be given to BFCO(96)3 issued by the Royal College of Radiologists which recommends permanent retention on a computer database when patients have been given chemotherapy and radiotherapy.

- Patients involved in clinical trials 15 years after conclusion of treatment. EEC Note for

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Record Type/Sub Type Retention Period (Years)

Notes

Guidance: Good Clinical Practice for Trials on Medicinal Products in the European Community, section 3.17 (see – Pharmacology & Toxicology 1990, 67, 361-372.)

Physiotherapy Retain for the period of time appropriate to the patient/speciality e.g. Childrens records should be retained as per the retention period for records of children and young people; mentally disordered persons 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.

Podiatry

Speech & Language Therapy

- General (not covered above) 8 years after conclusion of treatment.

Notes on preservation of patient records for historical purposes

1. In the light of the latest trends in health and historical research, it may be appropriate to select some of these records for permanent preservation. Selection should be performed in consultation with health professionals, and archivists from an appropriate place of deposit. If records are to be sampled, specialist advice should be sought from the same health professionals and archivists. If a NHS Organisation or Health Board has taken on a leading role in the development of specialised treatments, then the patient records relating to these treatments may be especially worthy of permanent preservation.

2. If a whole run of patient records is not considered worthy of permanent preservation but nevertheless contains some material of research value, then the option of presenting these records to local record offices and other institutions under S.3(6) of the Public Records Act 1958 should be considered. Advice on the presentation procedure may be obtained from the PRO’s Archive Inspection Services.

3. If a whole run of patient records is considered worthy of permanent preservation but there is a lack of space in the relevant place of deposit to store these records, it may be appropriate to make a microfilm copy and then destroy the paper originals. Microfilms should be produced in accordance with the British and International Standard BS ISO 6199: 1991, copies of which can be purchased from the British Standards Institute.

Notes on the destruction of confidential patient records

1. Destruction of confidential records must ensure that their confidentiality is fully maintained. Normally destruction should be by incineration or shredding. Where this service is provided by a contractor, it is the responsibility of the NHS Organisation or Health Board to satisfy itself that the methods used throughout all stages including transport to the destruction site provide satisfactory safeguards against accidental loss or disclosure.

Hospital Services 10

Health records See Hospital patient case records

Midwifery records See Hospital patient case records - Maternity records

Obstetric records See Hospital patient case records - Maternity records

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

Patient Activity Data 3

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Notes

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

X-ray films (including other image formats for all imaging modalities)

Local decisions should be made with regard to the preservation of these records, which are considered to be of transitory nature

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

X-ray reports (including reports for all imaging modalities)

To be considered as a permanent part of the patient record - See Hospital patient case records

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Appendix B: Guidance for General Medical Practices & Health Authorities on Preservation, Retention & Destruction of GP Health Records relating to patients. These Retention Periods only refer to GP Health Records. The term ‘GP Health Records’ is used to describe those records maintained by a general practitioner by virtue of his/her obligations under paragraph 36 of Schedule 2 to the NHS (General Medical Services) Regulations 1992 or under paragraph 20(1) of schedule 1 to the Directions to Health Authorities Concerning the implementation of pilot schemes (Personal Medical Services).

These records should be returned to the Health Board under the terms of this legislation on the death of the patient, or at the request of the Health Board (usually when the person is no longer a patient of the general practitioner). 1. Recommended Minimum Retention Periods for Records 1.1 The recommended Minimum Retention Periods for GP Patients’ Health Records


Maternity Records 25 Years Records relating to Children & Young People (including paediatric, vaccination & community child health service records)

Until the patient’s 25th Birthday or 26th if an entry was made when the young person was 17; or 10 years after death of patient if sooner.

Records relating to persons receiving treatment for a mental disorder within the meaning of the Mental Health Act 1983

20 years after no further treatment considered necessary; or 10 years after patient’s death if sooner.

Records relating to those serving in HM Armed Services

Not to be destroyed until 10 years after patient’s death

Records relating to those serving a prison sentence

Not to be destroyed until 10 years after patient’s death

1.2 After the appropriate minimum period has expired the need to retain record further

for local use should be carefully and necessary periodically, reviewed. Because of the sensitive and confidential nature of such records and the need to ensure that decisions on retention balance the interests of professional staff, including any research in which they are or may be engaged, and the resources available for storage, it is recommended that the view of the progression’s local representative should be obtained.

1.3 As records could be required in litigation virtually without limit of time, the Department of Health recognises that some records may be destroyed that might otherwise subsequently have been required for litigation. The Department of Health’s view, however, is that the cost of indefinite retention of records would greatly exceed the liabilities likely to be incurred in the occasional case where defence to an action for damages may be handicapped by the absence of records.

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2. General Storage 2.1 The Department of Health strongly recommends that GPs should make arrangements

for secure storage of records used and retained within the surgery.

2.2 Health Authorities are strongly recommended to make arrangements for secure preservation of records for the prescribed time as detailed in paragraph (1) in respect of patients who are no longer registered with a GP. In particular the accommodation should be secure, with proper environmental controls and adequate protection against fire and flood.

3. The use of Clinical Records 3.1 GPs are required by their terms of service to keep adequate records. The records

are used by doctors to help them in the diagnosis and treatment of their patients, and provide a history of a patient’s encounters with his GP. This means neither that it is necessary to retain every piece of paper or to record every item of data received in connection with a patient, nor that everything which is added to a record necessarily becomes a permanent feature of that record which can never be deleted. The Department of Health’s view is that the notes should record what is in the patient’s best interests and the details of any product which has been used in the course of treatment. Otherwise it is a matter for the judgement of health professionals acting on the advice of professional bodies and organisations to consider what is adequate for the purpose.

3.2 As part of this consideration Health Authorities, and others, may wish to give particular thought to the retention of any X-Rays that are held by the GP as part of the GP Medical Record. In a legal case “Hammond (Administrator of Estate of Mavis Hammond deceased) v West Lancashire Health Authority – Court of Appeal” the authority was criticised in connection with its handling of the early destruction of X-Rays and their relevance to the patient’s records.

4. Retention of Clinical Records 4.1 The Department of Health advises that the minimum retention period for the retention

of personal health records which are no longer required for clinical purposes should take account of the provisions of the Limitation Act 1980 and the Congenital Disabilities (Civil Liability) Act 19786 and the Consumer Protection Act 1987.

4.2 The Limitation Act 1980 amended the law on the time limits within which actions for personal injuries, or arising from death, may be brought. The limitation period for bringing such actions is 3 years. This period runs from when it is first realised that a person has suffered a significant injury that may be attributable to the negligence of a third party or from 10 years after the application of a product which is found to be defective. The lapse between the ‘injury’ and ‘knowledge’ of it is without limit of time. The congenital Disabilities (Civil Liability) Act 1976, clarifies the right of a child born disabled, as distinct from the right of his mother, to bring civil action for damages in respect of that disability. For a minor the limitation period runs from the time he attains the age of 18 years and may be extended where material facts are not known. The consumer Protection Act 1987 extends an obligation arising from liability for a defective product to ten years after the product was supplied by the producer.

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The NHS is affected by these provisions and may be liable as a supplier or user of a product.

4.3 A person of “unsound mind” can, as long as he remains under the disability in question, bring an action without limit of time through his ‘next friend”. After the person’s death, the period of limitation will run against his personal representative(s). Health Authorities and GPs will disorder persons; discharge from hospital can no longer be regarded as implying that the person has fully recovered from the disability.

4.4 The limitation period of three years applies only to actions which include a claim for damages in respect of personal injuries. In the case of other claims, e.g. a claim by a mentally disordered patient that he has been falsely imprisoned, the appropriate limitation period prescribed by Section 2(1) of the Limitation Act 1980 is six years from the date when the patient ceases to be under a disability or dies.

5. Computerised Records 5.1 With regard to the retention of records produced by computers the normal

consideration will apply where printed statements and records are produced. Where the records are held only a microfilm, microfiche or original magnetic data files, the Department of Health recommends that they should be retained, using the same criteria governing the retention of more conventional records, but taking extra care to prevent corruption or deterioration of the data. Re-recording/migration of the data may also need to be considered as equipment and software becomes obsolete.

6. Confidential Records 6.1 All NHS Bodies and those carrying out functions on behalf of the NHS have a

common law duty of confidence to patients and a duty to support professional ethical standards of confidentiality. Everyone working for or with the NHS who records, handles, stores, or otherwise comes across information has a personal common law duty of confidence to patients and his or her employer. The duty of confidence continues even after the death of the patient or after an employee or contractor has left the NHS.

6.2 In general, any personal information given or received in confidence for one purpose may not be used for a different purpose or passed to anyone else without the consent of the provider of the information. This duty of confidence is long established at common law.

6.3 The implementation in 1999 of the Data Protection Act 1998, which covers both computerised and certain manual personal data, will (by replacing the Data Protection Act 1984) establish a set of principles with which users of personal information must comply, such as the fair and lawful processing of information; the collection and processing of information only for specific purposes; information to be accurate and up to date; and retained in a form which identifies the subject only for as long as is necessary for the purpose.

6.4 The Caldicott Review of Patient Identifiable Information recommended that

“Guardians” of patient information should be created to safeguard and govern the uses made of confidential patient information within NHS organisation. Those

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responsible for the retention and destruction of GP Health Records should liase closely with their local Guardian to ensure that their local strategy is in line with national and local guidance and protocols on confidentiality.

6.5 The Caldicott Committee also recommended that NHS organisations should be held, accountable through clinical governance procedures, for continuously improving confidentiality and security procedures governing access to and storage of personal information.

6.6 Health Authorities are recommended to take care to ensure, before any GP Health Records are destroyed, that they are being destroyed in accordance with these guidelines. This is likely to involve, at some point, an examination of the record. Solicitors have advised that such an examination is necessary to comply with this guidance and with the laws of evidence. Doing so is in the public interest and therefore so long as the activity is confined to what is necessary in the public interest and the persons involved are made aware of their absolute duty of confidence Health Authorities should not be subject to a significant risk of a successful legal challenge. Health Authorities are; of course, free to seek their own legal advice on this point.

6.7 To ensure that confidentiality is fully maintained, the methods used for the destruction of confidential records need to be carefully considered. Normally destruction by incineration or shredding is recommended. Where this service is provided by a contractor it is the responsibility of the Health Board to satisfy itself that the methods used throughout all stages including transport to the destruction site provide satisfactory safeguards against accidental loss or disclosure.

7. Lost Records

7.1 GP Health Records can properly be destroyed using this guidance. However, despite our best efforts, from time to time the Health Records of patients do become wholly or partially lost in situations where it is clear that they should not have been lost or destroyed. This is particularly distressing for the individual concerned and, however infrequently it happens, can reflect badly on the NHS.

7.2 Health Authorities may wish to consider the merits of providing a patient with a named contact point when they receive a report relating to lost or missing Health Records. Every effort should be made using available information from, for example, the patient, general practice, Health Board records and NHS Central Registry to locate the missing records. A record of the actions taken to locate the record would help in the handling of any complaints subsequently lodged by the patient.

7.3 Health Authorities could also consider what action can be taken to minimise the impact of the loss, for example whether or not parts of existing hospital records might help reconstruct part of the patients medical history.

* For the purposes of the Limitation Act, a person of "unsound mind" is a person, who, by reason of mental disorder within the meaning of the Mental Health Act 1983, is incapable of managing and administering his property and affairs.

(The above definition is consistent with the definition of "disability" in the Supreme Court rules which prescribe how people under a disability mat bring an action.)

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This table should be completed and added at the end of the document: Members of the Working Group: Name Title

Consultation has taken place with: Name Title Date Consulted