Aneurin Bevan University Health Board Non Clinical and Clinical Records Retention Schedule

Transcription

1 Non Clinical and Clinical Records Retention Schedule N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document. Policy Number:

2 NON-CLINICAL AND CLINICAL RECORDS RETENTION SCHEDULE CONTENTS 1 POLICY STATEMENT INTRODUCTION RETENTION LEGISLATION Non-Clinical Record Types & Retention Periods: - Audit Reports 10 - Building, Estates & Property Management 10 - Contracts 12 - Contractor Records 12 - Corporate 13 - Equipment Records 14 - Financial 15 - Forms/Certificates/Registers 17 - General 18 - Hazard Notices 18 - Health & Safety/Risk Management 18 - Hotel Services 18 - Human Resources 18 - IT 20 - Salaries/Pension Records 20 - Supplies Department/Stores/Contracts 21 - Miscellaneous other Clinical Record Types & Retention Periods: 23 - Accident & Emergency Records /Registers 23 - Adoption (includes Preadoption) 23 - Admission Books Ward 23 - Ambulance Records 23 - Audiology 23 - Audit Trails (Electronic Health Records) 24 - Birth Notification 24 - Blood Gas Results 24 - Chaplaincy Records 24 - Child Health Records 24 - Child Protection Register 24 - Clinical Audit Records 24 1

3 - Clinical Diaries 24 - Community Records - Dental & Ophthalmic 25 - Contraception & Sexual Health 25 - Controlled Drug Documentation 25 - Creutzfeldt-Jakob Disease - Hospital & GP 25 - Death - cause of, Certificate Counterfoils 25 - Dental Epidemiological Surveys 25 - Dental, Ophthalmic & Auditory Screening Records (incl. Orthodontics) 26 - Dietetic & Nutrition 26 - District Nursing Records 26 - DNA (health records for patients who Did Not Attend) 26 - Donor Records (blood and tissue) 27 - Electrocardiogram Records 27 - Electronic Patient Records 27 - Endoscopy Records 27 - Family Planning Records 27 - Genetic Records 28 - Genito-Urinary Medicine 28 - GP Records (and medical records relating to HM Armed forces/prisons) 28 - Health Records - persons under medical surveillance 29 - Health Visitor Records 29 - Homicide/Serious Untoward Incident Records 29 - Hospital Acquired Infection Records 29 - Hospital Records - non specific 29 - Human Fertilisation Records 30 - Human Tissue Records 30 - Immunisation & Vaccination Records 30 - Intensive Care Unit Charts 31 - Joint Replacement Records 31 - Laboratory Records 31 - Learning Difficulties (patient records) 33 - MacMillan Cancer Care Records 33 - Mammography Screening Records 34 - Maternity (all obstetric and midwifery records) 34 - Mental Health Act Administration Records 34 - Mental Health Records & CAMHS 34 - Microfilm/Microfiche Records 35 - Mortuary Registers 35 - Music Therapy Records 35 - Neonatal Screening Records 35 - Occupational Health Records (staff) 35 - Occupational Related Disease Records 35 2

4 - Occupational Surveillance Health Records 35 - Occupational Therapy Records 35 - Oncology Records 35 - Operating Theatre Lists 36 - Operating Theatre -Recovery Room Registers 36 - Orthoptic Records 36 - Outpatient Lists 36 - Parent Held Records 36 - Patient Held Records 36 - Patient Information Leaflets 36 - Patient Surveys 36 - Phone Message Books 36 - Photographs 37 - Physiotherapy Records 37 - Podiatry Records 37 - Police Statements 37 - Private Patient Records 37 - Psychology Records 38 - Psychotherapy Records 38 - Psychiatric Records 38 - Records of destruction 38 - Referral letters (where care is not accepted) 38 - Research Records 38 - Scanned Records 40 - Speech & Language Therapy Records 40 - Suicide Records 40 - Surgical Appliance Records 40 - Transplantation 40 - Ultrasound 40 - Video Records/ Voice Records 41 - Vulnerable Adults 41 - X-ray Registers 41 - X-ray films and other modalities 42 - X-Ray Referral/Requests cards 42 - Wards Admission/Discharge Books 42 7 APPENDIX A APPENDIX B 45 APPENDIX C 46 3

5 1 POLICY STATEMENT This policy complies with the Welsh Assembly s Guidelines WHC (2000) 71 Health Circular: For the Record Managing Records in NHS Trusts and Health Authorities and the Department of Health - Records Management Code of Practice. The Circular: 1. Sets out the legal obligations for all NHS Bodies to keep proper records 2. Outlines the action required from Chief Executives, Senior Managers, Line Managers and Supervisors to fulfil these obligations 3. Explains the requirements for the selection of records for permanent preservation 4. Lists suggested minimum periods for the Retention of NHS Records The aim is to minimise record storage and retrieval, improve the standard of record keeping and ensure clinical information requirements are maintained. This Policy applies to all records held within the Acute, Community, Child Health, Mental Health and Learning Disability Services. This policy is applicable to all records whether they are in paper format, scanned or electronic records (see Appendix B). All NHS records are public records under the terms of the Public Records Act 1958, which confers a statutory duty on Trusts/Health Boards for the safekeeping and eventual disposal of the records as detailed in the Department of Health & Guidance Records Management: NHS Code of Practice and the requirements of the Freedom of Information Act (FOIA) The Chief Executive and Senior Managers are personally accountable for the quality of records management. Senior Managers are responsible for ensuring that staff are adequately trained and apply the appropriate guidelines. Individual members of staff are responsible for any records they create or use. This Policy also takes into account the Department of Health & NHS Code of Practice 2009 revised policy. 2 INTRODUCTION The Public Records Act 1958 requires that there is a systematic and planned approach to the management of records within an organisation from their creation and maintenance to their ultimate disposal. Records are a valuable resource because of the information they contain. High-quality information underpins the delivery of high-quality evidence-based healthcare, and many other key service deliverables. Information has most value when it is accurate, up to date and accessible when it is needed. An effective records management service ensures that information is properly managed and is available whenever and wherever there is a justified need for that information, and in whatever media it is required. Information may be needed: to support patient care and continuity of care; to support day-to-day business which underpins the delivery of care; to support evidence-based clinical practice; 4

6 to support sound administrative and managerial decision making, as part of the knowledge base for NHS services; to meet legal requirements, including requests from patients under subject access provisions of the Data Protection Act or the Freedom of Information Act; to assist clinical and other types of audits; to support improvements in clinical effectiveness through research and also to support archival functions by taking account of the historical importance of material and the needs of future research; or to support patient choice and control over treatment and services designed around patients.. The Caldicott Guardian is responsible for approving and ensuring that national and local guidelines and protocols on the handling and management of confidential personal information are in place. Ownership and copyright of NHS records as a rule lie with the NHS Board, not with any individual employee or contractor. The key statutory requirement for compliance with records management principles is the Data Protection Act It provides a broad framework of general standards that have to be met and considered in conjunction with other legal obligations. The Act regulates the processing of personal data, held both manually and on computer. It applies to personal information generally, not just to health records, therefore the same principles apply to records of employees held by employers, for example in finance, personnel and occupational health departments bodies likely to comment on records management performance include the Health Service Ombudsman when investigating a complaint, and the Information Commissioner when investigating alleged breaches of Data Protection or Freedom of Information legislation or in promoting the Lord Chancellor s Code of Practice on Records Management under section 46 of the Freedom of Information Act 3 RETENTION This policy is based on Welsh Health Circular WHC (2000) 71 For the Record Managing Records in NHS Trusts and Health Authorities which details the legal minimum recommended periods for the retention and destruction of records and the Department of Health Code of Practice on the Retention of Records. A record of the destruction of records, showing their reference, description and date of destruction should be maintained and preserved by the Records Manager, so that the organisation is aware of those records that have been destroyed and are therefore no longer available. Disposal schedules would constitute the basis of such a record. If a record due for destruction is known to be the subject of a request for information, or potential legal action, destruction should be delayed until disclosure has taken place or, if the authority has 5

7 decided not to disclose the information, until the complaint and appeal provisions of the Freedom of Information Act have been exhausted or the legal process completed Health Records Destruction All records falling into the category of being selected for destruction will be destroyed after meeting the following criteria. All retention categories have been complied with Records will be identified either by manual or computer methodology Records will be physically checked to ensure that there are no entries relating to a later date All health records will be manually checked to ensure that they contain no Advanced Directives (Living Wills) Health Records will be marked as destroyed on the relevant computer systems on which details of the patient records are held e.g. Myrddin, Epex, EMIS, CCIS etc Records for destruction will be destroyed in accordance with the appropriate Confidential Waste Policy. 4 LEGISLATION This policy and the guidelines on retention recognise and take into account such documentation as: The Abortion Regulations 1991 The Access to Health Records Act 1990 The Access to Medical Reports Act 1988 Administrative Law The Blood Safety and Quality Regulations 2005 Directive 2002/98/EC of the European Parliament and of the Council of 27 January 2003 Commission Directive 2005/61/EC of 30 September 2005 The Census (Confidentiality) Act 1991 The Civil Evidence Act 1995 The Common Law Duty of Confidentiality Confidentiality: NHS Code of Practice The Computer Misuse Act 1990 The Congenital Disabilities (Civil Liability) Act 1976 The Consumer Protection Act (CPA) 1987 The Control of Substances Hazardous to Health Regulations 2002 The Copyright, Designs and Patents Acts 1990 The Crime and Disorder Act

8 The Data Protection Act (DPA) 1998 The Data Protection (Processing of Sensitive Personal Data) Order 2000 Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the Community Code Relating to Medicinal Products for Human Use The Disclosure of Adoption Information (Post-Commencement Adoptions) Regulations 2005 The Electronic Communications Act 2000 The Environmental Information Regulations 2004 The Freedom of Information Act (FOIA) 2000 The Gender Recognition Act 2004 The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) (No. 2) Order 2005 The Health and Safety at Work Act 1974 The Human Fertilisation and Embryology Act 1990, as Amended by the Human Fertilisation and Embryology (Disclosure of Information) Act 1992 The Human Rights Act 1998 The Limitation Act 1980 The NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000 The Police and Criminal Evidence (PACE) Act 1984 The Privacy and Electronic Communications (EC Directive) Regulations 2003 Public Health (Control of Diseases) Act 1984 and Public Health (Infectious Diseases) Regulations 1988 The Public Interest Disclosure Act 1998 The Public Records Act 1958 The Radioactive Substances Act 1993 The High-activity Sealed Radioactive Sources and Orphan Sources Regulations The Re-use of Public Sector Information Regulations 2005 The Sexual Offences (Amendment) Act 1976 Subsection 4(1) as Amended by the Criminal Justice Act

9 Non Clinical Record Types and Retention Periods Audit Reports Audit Reports original documents (e.g. Organisational Audits, Records Audits, System Audits) Internal and External Audit Reports (including Management Letters, VFM reports and system/final accounts memorandum) 2 years From completion of the audit 2 years After formal clearance by Statutory Auditor Building Estates & Property Management Buildings and engineering works, inclusive of major projects abandoned or deferred town and country planning matters and all formal contract documents e.g. executed agreements, conditions of contract, specifications, as built record drawings and documents on the appointment and conditions of engagement of private buildings and engineering consultants Buildings and engineering works, inclusive of major projects, abandoned or deferred key records, e.g. final accounts, surveys, site plans, bills of quantity Buildings papers relating to occupation of the building (but not health and safety information) Contracts financial Deeds of Title 30 years 30 years 3 years after occupation ceases Approval plans 15 years Approved suppliers lists 11 years Retain while organisation has ownership of the building unless a Land Registry certificate has been issued, in which case the deeds should be placed in an archive. If there is no Land Registry certificate, the deeds should pass on with the sale of the building Approved by: Executive Team Review by date: 13 April

10 Building Estates and Property Management (cont) Drawings plans and buildings (architect signed, not copies) Engineering works plan and building records Equipment procurement, use, modification and supply records relevant to production of products (diagnostics) or equipment Equipment- instruments maintenance logs, records of service inspections Lifetime of the building to which they relate Lifetime of the building to which they relate 11 years See Products Liability Lifetime of equipment Estates - Approved Suppliers Lists 11 years Consumer Protection Act 1987 Estimates: including supporting calculations and statistics 3 years Inspection Reports e.g. boilers, lifts etc. Lifetime of installation Normally retain for the lifetime of an installation. However, it is necessary to assess whether obligations incurred during the lifetime may be invoked afterwards, in which case a judgement must be made. If there is any measurable risk of a liability in respect of installations beyond their operational lives, records of this kind should be retained indefinitely Inventories (not in current use) of items having a life of less than 5 years 1.5 years Inventories Keep until next inventory Furniture, medical and surgical equipment not held on store charge and with a minimum life of 5 years Land Survey/Registers * Recommended permanent preservation Leases * Recommended permanent preservation Manuals operating Lifetime See Inspection reports Manuals policy and procedure * Recommended permanent preservation Maps * Recommended permanent preservation Mortgage documents (acquisition, transfer and disposal) 6 years after repayment 9

11 Building Estates and Plans Building (As built) * Recommended permanent preservation Property Management Plans Building (Detailed) Lifetime See Inspection reports (cont) Plans Engineering Lifetime See Inspection reports Products Liability 11 years Consumer Protection Act 1987 Contracts Property Acquisitions Dossiers Property Disposal Dossiers Permanent Permanent Structure Plans (LA s) Lifetime of a building Organisational charts i.e. the structure of the building plans Surveys building and engineering works * Recommended permanent preservation Tenancies Agreement 7 years Government Regulations Title Deeds Contracts - non sealed (property) on termination Contracts - non sealed (other) on termination See Deeds of Title 6 years The Limitation Act, years The Limitation Act, 1980 Contracts - sealed 15 years Contracts under seal and associated records should be kept for a minimum of 15 years Contracts financial Project files (over 100,000) on termination - including abandoned or deferred projects Project files (less than 100,000) on termination Project Team Files -summary retained 15 years 11 years 6 years 2 years 3 years Approval files Approved suppliers lists Site Files As per contracts Specifications 6 years The Limitation Act

12 Contractor Records Ophthalmic Opticians, Ophthalmic Medical Practitioners, Pharmacists, Pharmacy Premises, General Optical Council amendments to the register, previous Pharmacy rotas and supporting information (prior to 2005 new regulations), copies of previous Pharmacy and Ophthalmic local lists, correspondence relating to pharmacies supplying oxygen and visiting Residential/Nursing Homes (prior to new regulations). Doctors Postgraduate Educational Allowance/ Personal Development Plan files and supporting general correspondence 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. GP seniority (prior to 2004 new regulations) Corporate Agendas See meeting papers Annual Corporate Reports Assembly/Parliamentary Questions/MP Enquiries 3 years Subject to paragraph 8(5) a contractor shall retain all such records for a period of 7 years and shall during that period produce them when required to do so by the Health Board or the Minister for Health. 10 years As these documents include all information provided by the organisation in response to an Assembly /Parliamentary Question e.g. background note to the Minister or the Minister may amend the response) all of which may not be used in the response therefore it will not be in the public domain they must be destroyed under confidential conditions. History of organisation or predecessors, its organisation and procedures Complaints Copyright declaration forms 30 years Archivist should be contacted 6 years See Litigation dossiers Data input forms 2 years Where data/information has been input into a computer system 11

13 Corporate (cont) Diaries - desk/administration office on completion 1 year Freedom of Information requests History of organisation or predecessors its organisation and procedures e.g. establishment order Hospital (trust) services i.e. service that the Trust provides e.g. catering, hotel services Indices Litigation Dossiers (complaints including accident reports) Record/documents relating to any form of litigation Meeting and minutes papers of major committees and sub-committees (master copies) Meetings and minutes papers (other, including reference copies of major committees) Minutes reference copies 3 years after full disclosure and 10 years if information is redacted or the information requested is not disclosed 30 years 10 years Registry lists of public records marked for permanent preservation or containing the record of management of public records 30 years 10 years Where a legal action has commenced, keep as advised by legal representatives 30 years 2 years 1 year File and document lists where public records or their management are not covered 30 years 12

14 Corporate (cont) Press cuttings 1 year Equipment Records Press Releases Public Consultations e.g. about future provision of services Quality and Outcomes Framework Reports (major) Research ethics committee records 7 years 5 years 2 years Permanent 3 years from date of decision Serious Incident Files * These documents must be considered for permanent preservation. Trust documents without permanent relevance Equipment/instruments/maintenance logs, records of service inspections Procurement, use, modification and supply records relevant to production of products (diagnostics) or equipment 6 years Lifetime of equipment 11 years Financial Accounts Annual (Final one set only) Permanent See products Liability Hazard Notices Local decisions etc If the records relate to vehicles (ambulances, responder cars, fleet vehicles etc.,) and where the vehicle no longer exists, providing there is a record that it was scrapped, the records can be destroyed Accounts Cost Accounts Working Papers Accounts Minor records (pass books: paying-in slips; cheque counterfoils; cancelled/discharged cheques (other than cheques bearing printed receipts - see Receipts); accounts of petty cash expenditure; travelling and subsistence accounts; minor vouchers; duplicate receipt books; income records; laundry lists and receipts) 3 years 3 years 2 years from completion of audit 13

15 Financial (cont) Audit Records (including Management Letters, VFM reports and system/final accounts memorandum) as advised by External Auditors Audit Records - original documents (as advised by External Auditors) 2 years After formal clearance by Statutory Auditor 2 years From completion of the audit Bank Statements 2 years From completion of the audits Benefactions Bills, receipts and cleared cheques 5 years after the end of the financial year in which the Health Board spends the monies or the gift in kind is accepted. Where the Benefaction Endowment Trust fund/capital/interest remains permanent records should be permanently retained. 6 years Recommended permanent preservation Budget Variaments 6 years From completion of the last External audit Budgets 2 years From completion of the audit Capital charges data 2 years From completion of the audit Capital paid invoices 6 years See Invoices Cash Books 6 years The Limitation Act 1980 Cash Sheets 6 years The Limitation Act

16 Financial (cont) Charitable Funds 30 years Company charities are required by company law to keep their accounts and accounting records for minimum 3 years but Charity Commission recommends 6 years. Non-Company charities must keep accounts and accounting records for 6 years (Part VI Charities Act, 1993) Although classed as exempt from The Public Records Act, it is appropriate to treat these records as if they are not exempt Cost accounts 3 years after end of financial year to which they relate Creditor payments 3 years after end of financial year to which they relate Debtors records cleared 2 years From completion of the audit Debtors records uncleared 6 years From completion of the audit Demand notes 6 years after end of financial year to which they relate Expense claims, including travel and subsistence claims and authorisations Financial records Fraud Case Files/investigations 5 years after end of financial year to which they relate 6 years See under individual headings. However, once the period of retention for audit purposes is complete (2 years from completion of audit), documents not required for permanent preservation may be destroyed provided a properly compiled microfilm record is retained for the remainder of the prescribed period, embodying a suitable certificate by the treasurer as to its accuracy and completeness. This does not apply to forms SD55 (ADP) and SD55J 15

17 Financial (cont) Fraud national proactive exercises 3 years Funding data 6 years after end of financial year to which they relate Income and expenditure journals 6 years Invoices 6 years after end of financial year to which they relate. Limitation Act 1980 Ledgers including cash books, ledgers, income and expenditure journals, nominal rolls etc Mortgage documents (acquisition, transfer and disposal) 6 years after end of financial year to which they relate Permanent Nominal rolls 6 years (maximum) As a general rule, it may be appropriate for only the current nominal roll and the immediately preceding roll to be kept Payments 6 years after end of financial year to which they relate Payroll (ie list of staff in the pay of the organisation Private Finance Initiative 6 years after termination of employments 30 years Receipts 6 years The Limitations Act 1980 Receipts for registered and recorded mail 2 years after end of financial year to which they relate Superannuation accounts Tax forms VAT Records 10 years 6 years 6 years 16

18 Forms/Certificates/ Registers Abortion Certificate A (For HSA1) and Certificate B (Emergency Abortion) Body Release Forms 3 years Abortion Regulations 1991, Statutory Instrument No years Deaths Cause of, Certificate counterfoils 2 years Forms Surgical Appliances AP1, 2, 3 and 4 Forms Superannuation SD55 (ADP) and SD55J (copies) 2 years From completion of audit 10 years Originals are sent to NHS Pensions Agency FP10, TTO s outpatient and private 2 years Electronic Patient Records will eventually hold all these details` GMS1 forms (registration with GP) 3 years Indices Permanent Registry lists may describe public records marked for permanent preservation, or contain the record of management of public records. They should in these cases be retained permanently. File-lists and document lists, where public records or their management are not covered, should be retained until they have no further administrative use Receipt for registered and recorded delivery mail 1.5 years General Quality Assurance Records 12 years Research* Development (Scientific, Technological and Medical) * These documents must be considered for permanent preservation. Hazard Notices 5 years As per Solicitor s advice 17

19 Health and Safety/Risk Management Accident Books 3 years After last entry Accident Forms/Books 10 years Where legal action has been commenced, keep as advised by legal representatives Accident Register (RIDDOR) 10 years Reporting of injuries, diseases and dangerous occurrences regulations, reg. 7; Social Security (Claims and Payments) Regulations, reg. 25 Close Circuit TV images 31 days As per the Information Commissioner s Code of Conduct these need to be erased permanently Hazard Notices Health and Safety Documentation Incident Forms Risk Assessments 3 years 10 years Retain the latest one until a further assessment replaces it As per Legal advice Serious Incident Files * Recommended permanent preservation IRI Form, blue copy Local decisions should be taken with regard to these. Hotel Services Laundry Lists and Receipts 2 years From completion of the audit Record of custody and transfer of keys 2 years after last entry Human Resources Advance Letters 6 years CVs for non-executive directors (successful) CVs for non-executive directors (unsuccessful applicants) Duty Rosters 5 years Following term of office 2 years 4 years after the year to which they relate Organisation or departmental rosters, not the ones held on the individuals record 18

20 Human Resources (cont) Establishment records - major (e.g. personal files, letters of appointment, contracts, references and related correspondence) Establishment records minor (e.g. attendance books, annual leave records, duty roster, clock cards, timesheet) 6 years Keep for 6 years after subject of file leaves service, or until subject's 70th birthday, whichever is the later. Only the summary needs to be kept to age 70' remainder of file can be destroyed 6 years after subject leaves service 2 years FWH Personal Record of Hours Actually Worked Industrial Relations (not routine staff matters) Job advertisements 0.5 years * Recommended for permanent preservation 1 years Job Applications (following termination of employment) Job Descriptions (following termination of employment) Letters of appointment 3 years 3 years See Establishment records major Leavers Dossiers (provided summary retained) Personnel Files Staff Records Study Leave Applications 6 years after individual has left. Summary to be retained until individual s 70 th birthday or until after cessation of employment if aged over 70 years at the time. Summary should contain everything except attendance books, annual leave, duty rosters, clock cards, timesheets, study leave applications and training plans. 5 years 19 See Establishment records major See Establishment records major Subject Files * Recommended permanent preservation

21 Information Technology Computerised records The recommended minimum retention periods apply to both paper and computerised records, though extra care needs to be taken to prevent corruption or deterioration of the data. Re-recording/migration of data will also need to be considered as equipment and software become obsolete. For guidance, see the Public Record Office guidance, Management and Appraisal of Electronic Records (1998) Salaries/Pension Records Documentation relating to computer programmes written in-house Software Licences Patient Activity Data Lifetime of software Lifetime of software 3 years Expense claims 2 years From completion of audit Pay Roll - full time medical staff 6 years For superannuation purposes authorities may wish to retain such records until the subject reaches benefit age Pay Roll - other staff 6 years PAYE Records Pension Forms all 6 years 7 years Wages/Salaries Records 10 years For superannuation purposes authorities may wish to retain such records until the subject reaches benefit age Salaries See Wages Superannuation Accounts Superannuation Registers 10 years 10 years 20

22 Supplies Department/ Stores/Contracts Time Sheets 2 years after the year to which they relate NB Time sheets (for all individuals including locum doctors) held on the personnel record are minor records 2 years Timesheets held elsewhere i.e. on the ward retain for 6 months(as the master timesheet is held on the personnel file) Time Sheets 6 months NB Relating to a group of Department e.g. Ward where the timesheets are kept as a tool to manage resources, staffing levels Advice notes Agreements 1.5 years See Contracts Approval Files (Contracts) * Recommended permanent preservation Approved Suppliers Lists 11 years Consumer Protection Act 1987 Delivery Notes 2 years After end of financial year to which they relate Inventories (not in current use) of items having a life of less than 5 years Maintenance contracts routine 1.5 years See contracts Products liability 11 years Consumer Protection Act 1987 Project Files (over 100,000) on termination including abandoned or deferred projects Project Files (less than 100,000) on termination * Recommended permanent preservation 6 years 21

23 Project Team Files summary retained 3 years Requisitions 1.5 years Site Files See Contracts Specifications 6 years The Limitation Act 1980 Stock Control Reports Stores Records major (stores, ledgers etc) Supplies Records minor (e.g. invitations to tender and inadmissible tenders, routine papers relating to catering and demands for furniture, equipment, stationery and other supplies Tenders (successful) 1.5 years 6 years 1.5 years See Contracts Tenders (unsuccessful) 6 years The Limitation Act 1980 Miscellaneous Records Biomedical Engineering Sterilix Endoscopic Disinfector Daily Water Cycle Test Sterilix Endoscopic Disinfector daily Water Purge Test Nynhydrin Test 11 years 11 years Close Circuit TV images 31 days As per the Information Commissioner s Code of Conduct these need to be erased permanently Close Circuit TV images 22

24 Chaplaincy Records 2 years Research & Development (scientific, technological and medical) External quality control records Internal quality control records relating to products Nurses Training Records 30 years All the organisation s records associated with research and development and not individual trial records or information on patients. 2 years 10 years 30 years 23

25 CLINICAL RECORD TYPES AND RETENTION PERIODS Accident and Emergency records (where these are stored separately from the main patient record) Accident and Emergency Register Adoption records (i.e. administrative records relating to the adoption process) Pre-Adoption Records Records, where the NHS number has been changed following adoption, will be returned to the appropriate Child Health Team and they should be held for the same period of time as all records for children and young people. Genetic information should be transferred across to the post adoption record Retain for the period of time appropriate to the patient/speciality, e.g. children s A&E records should be retained as per the retention period for the records of children and young people. 8 years after the year to which they relate 75 th anniversary of the date of birth of the child to whom it relates or, if the child dies before attaining the age of years beginning with the date of the 18 th birthday Until the patient s 25th birthday, or 26th if young person was 17 at conclusion of treatment; or 8 years after patient s death occurred before 18th birthday Local decisions should be made with regard to the permanent preservation of these records, in consultation with relevant health professionals and places of deposit See Pre-adoption records below If the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the advice of clinicians should be sought as to whether to retain the records for a longer period Admission Books Ward 8 years since last entry Where they exist in paper format Ambulance records- patient identifiable component To include paramedic records made on behalf of the Ambulance Service 10 years for ALL Ambulance Clinical Records Where patient is transferred to the care of another NHS organisation all relevant clinical information must be transferred to the patients health record held at that organisation 24

26 Audiology records Audit trails (Electronic Health Records) Birth Notification Blood gas results Retain for the period of time appropriate to the patient/speciality. Organisations are advised to retain all audit trails until further notice Retain until the patients 25 th birthday or 26 th if young person was 17 at conclusion of treatment or 8 years after death Retain for the period of time appropriate to the patients/speciality eg children s record should be retained as per the retention period for the records of children and young people, mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record of 8 years after the patient s death, if patient died while in the care of the organisation See Appendix B Chaplaincy Records 2 years Likely to have archival value Child Health Records (notification of Visitors/New Entrants into a borough either from abroad or within the UK from Airports, the Home Office Immigration Centre and Housing Options Teams) Database of notifications entries should be retained for 2 years. Where the health visitor visits the child the record of the visit should become part of the patient s record and retained until their 25 th birthday or 26 th birthday if an entry was made when the patient was 17 years or 10 years after the patient s death, if the patient died while in the care of the organisation. This also applies to any other information that related to patient care recorded by the health visitor for these purposes. Other information should be retained for a period of 2 years from the end of the year to which it relates. If the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the clinician should advise as to whether the records are retained for a longer period. 25

27 Clinical Audit records 5 years Clinical Diaries Community Records Dental and Ophthalmic Contraception and Sexual Health Records (including where a scan is undertaken prior to termination of pregnancy but the patient goes elsewhere for the procedure Controlled drug documentation All types of clinical diaries to include health visitors, district nurses and Allied Health Professionals Removed from Pharmacy Records 2 years after end of year to which diary relates. 11 years adults Children 11 years or up to their 25 th birthday whichever if the longer Adults retain for 8 years Children as per previous guidance 8 years (in adults) or until 25 th birthday in a child (age 26 if entry made when young person was 17) or 8 years after death Requisitions 2 years Registers and CDRB s 2 years from last entry Extemporaneous preparation worksheets 13 years Aseptic worksheets (adult) 13 years Aseptic worksheets (paediatric) 26 years External orders and delivery notes 2 years Prescriptions (inpatients) 2 years Prescriptions (outpatients) 2 years Clinical Trials 5 years minimum (may be longer for some trials) Destruction of CD s 7 years Specific patient information should be transferred to the patient records. Any notes made in the diary as an aide memoire must also be transferred to the patient record as soon as possible after the event. Includes auditory screening records and Orthodontic records and models If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain the records for a longer period. NB Future regulations may increase the period of time for the storage of records. Please refer to Department of Health and Royal Pharmaceutical Society of Great Britain for up to date information 26

28 Death Cause of, Certificate counterfoils 2 years Dental epidemiological survey Dental, ophthalmic and auditory screening records including Orthodontic Records and Models Dietetic and nutrition Parenteral nutrition District nursing records Community Records Hospital Records 30 years 11 years for adults For children 11 years or up until their 25 th birthday Adult records 8 years Children & Young People - Retain until the patients 25 th birthday or 26 th if young person was 17 at conclusion of treatment or 8 years after death Retain for the period of time appropriate to the patient/speciality e.g. children s records and young people, mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after death if patient died while in the care of the organisation. 2 years Retain for the period of time appropriate to the patient/speciality e.g. children s records and young people, mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after death if patient died while in the care of the organisation. British Dental Association guidance Guidance for Dietitians for Records and Record Keeping - BDA Original valid prescription should be kept in patient s notes 27

29 DNA (health records for patients who DID NOT ATTEND for appointments as outpatients Donor Records (blood and tissue) Electrocardiogram (ECG) Records Electronic patient records (EPR s) Where there is no letter or correspondence informing the healthcare professional/organisation that has referred the client/patient /service user that the patient did not attend and no further appointment has been given Retain for the period of time appropriate to the patient specialty children s records and young people, mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after death if patient died while in the care of the organisation 30 years post transplantation Committee on Microbiological Safety of Blood and Tissues for Transplantation (MSBT); guidance issued years Each chart should be labelled with the patient s name and unique identifier. Any over-sized charts could then be stored separately where a report is written into the health record. Must not be destroyed or deleted for the foreseeable future See Appendix B for further information Endoscopy Records Family Planning records See also Contraception and Sexual Health Records Retain for standard retention periods i.e. 8 years for adults and in the case of children and young people retain until the patients 25 th birthday or 26 th if young person was 17 at conclusion of treatment or 8 years after death. For records of adults retain for 10 years after last entry. For clients under 18 retain until 25 th birthday or for 10 years after last entry, whichever is the longer i.e. records for clients aged should be retained for 10 years and records for clients under 16 should be retained until age 25 Including: Sterilix Endoscopic, Disinfector, Traceability Strips, Traceability Sticker for PEG/Stents If illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain the records for a long period. Records of deceased patients should be retained for 8 years after death. 28

30 Genetic records 30 years from date of last attendance Royal College of Pathologists endorses the Code of Practice and Guidance of the Advisory Committee on Genetic Testing (1997) and its recommendations on storage, archiving and disposal of specimens and records related to human testing services offered and supplied direct to the public. Genito Urinary Medicine (GUM) GP Records including medical records relating to HM Armed Forces or those serving a period of imprisonment For records of adults retain for 10 years after last entry. For clients under 18 retain until 25 th birthday or for 10 years after last entry, whichever is the longer i.e. records for clients aged should be retained for 10 years and records for clients under 16 should be retained until age 25 (i.e. still retained for at least 10 years) Records of deceased patients should be retained for 8 years after death. GP Records wherever they are held, other than the records list below should be retained for 10 years after death or after the patient has permanently left the country unless the patient remains in the EU. In the case of a child, if the illness or death could have genetic implications for the family of the deceased, the advice of the clinician should be sought as to whether the record is retained for a longer period Maternity Records 25 years after last live birth Faculty of Sexual and Reproductive Healthcare (FRSH) of the Royal College of Obstetricians and Gynaecologists and British Association for Sexual Health and HIV (BASHH) Limitation Act 1980, Congenital Disabilities (Civil Liability) Act 1976, Consumer Protection Act

31 Mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last contact or 10 years after death if sooner Royal College of Psychiatrists NB GP s may wish to keep mental health records for up to 30 years before review. They must be kept as complete records for the first 20 years but may be summarised and retained in summary format for a further 10 years GP Records including medical records relating to HM Armed Forces or those serving a period of imprisonment (cont) Armed Forces Records relating to those serving in HM Armed forces The Ministry of Defence retains a copy of the records relating to service medical history. The patient may request a copy of these under the Data Protection Act and give them to their GP. GPs should also receive summary records when ex-service personnel register with them. Not to be destroyed GP records of serving military personnel that were in existence prior to them enlisting. Following the death of the patient the records should be retained for 10 years after death. Records relating to those serving a prison sentence Not to be destroyed Refers to GP records of serving prisoners that were in existence prior to their imprisonment. Following the death of the patient the records should be retained for 10 years after death Health Records persons under medical surveillance 50 years from date of the last entry or age 75, whichever the longer Health Visitor Records 10 years. Records relating to children should be retained until their 25 th birthday Homicide/serious untoward incident records Hospital acquired infection records 30 years 6 years 30

32 Human fertilisation records, including embryology records Human fertilisation records, including embryology records (cont) Treatment Centres 1. Where it is known that a birth has resulted from treatment 25 years after the child s birth 2. Where it is known that no birth has resulted from treatment 8 years after conclusion of treatment 3. Where outcome of treatment is unknown 50 years after the information was first recorded Storage Centres Where gametes, etc. have been used in research, records must be kept for at least 50 years after the information was first recorded HFEA Data Protection Policy Version 2 Release Date 27/07/2007 Directions given under the Human Fertilisation and Embryology Act, January 1992 (Act subject to review by Government). Human Tissue (within meaning of the Human Tissue Act 2004) 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) For post mortems which form part of the Coroner s report, approval should be sought from the Coroner for a copy of the report to be incorporated in the patient s notes, which should then be kept in line with the speciality and then reviewed All other records retain 30 years Applies to centres in respect of information which they are directed to record and maintain under a treatment/storage licence The Retention and Storage of Pathological Records and Archives (3 rd Edition 2005) guidance from the Royal College of Pathologists and the Institute of Biomedical Science Human Tissue Act

33 Intensive Care Unit charts Joint replacement records Laboratory Records For joint replacement surgery the revision of a primary replacement may be required for the lifetime of the patient and there is a need to identify which prosthesis was used originally. Accreditation documents; records of inspections Batch Records results (relating to products) Blood gas results Blood Donor records and tissue Retain for the period of time appropriate to the patient/speciality i.e. adult 8 years, children and obstetrics 25 years, Mental Health 20 years from the date of last entry into the record Local decision - Lifetime of the patient and 8 years after death* *There is only a need to retain the minimum of notes with specific information about the original prosthesis for the lifetime of the patient 10 years or until superseded Retention schedules are under review by the Royal College of Pathologists check RCP website 10 years Consumer Protection Act 1987 Retain for the period of time appropriate to the patient/specialty 30 years post transplantation Blood for grouping, antibody screening and saving and/or cross matching Cervical Screening slides Day books and other records of specimens received by a laboratory Electrophoretic strips and immunofixation plates External quality control records Foetal serum 1 week at 4ºC 10 years 2 calendar years 5 years Unless digital images taken, in which case 2 years and stored as a photographic record 2 years 30 years 32

34 Laboratory Records (cont) Frozen tissue or cells for histochemical or molecular genetic analysis 10 years Grids for electron microscopy 10 years Human DNA Laboratory file cards or other working records of test results for named patients Microbiological cultures Museum specimens(teaching collections) Stained slides 4 weeks after final report for diagnostic specimens. 30 years for family studies for genetic disorders (consent required) 2 calendar years hours after final report of a positive culture issued. 7 days for certain specified cultures see RCPath document Permanently Depends on the purpose of the slide see RCPath document Consent of the relative is required if it is tissue obtained through post mortem Newborn blood spot screening cards 5 years Parent should be alerted to the possibility of contact from researchers after this period and a record kept of their consent to contact response Newborn - Body fluids /aspirates/ swabs 48 hours after the final report issued by lab Paraffin block 30 years Then appraise for archival value+ Post Mortem Report copies Post Mortem reports 6 months Held in patients health record for 8 years after the patient s death 33

35 Laboratory Records (cont) Records relating to investigation or storage of specimens relevant to organ transplantation semen or ova 30 years if not held with the health record Records relating to donor or recipient sera 11 years post transplant Results of antibody screening, grouping and other blood transfusion relate tests 30 yes to allow full traceability of all blood products used EU Directive 2002/98/EC The Blood Safety an Quality Regulations 2005 Standard Operating Procedures (current and old) 30 years Separated serum/plasma,stored for transfusion purposes Up to 6 months Serum following needlestick injury of hazardous exposure 2 years Serum from first pregnancy booking visit 1 year Learning Difficulties (patient records) Wet tissue (representative aliquot or whole tissue or organ) Whole blood samples, for full blood count Patients with Learning Difficulties Records 4 weeks after final report for surgical specimens 24 hours Retain for the period of time appropriate to the patient/speciality e.g. children s records and young people, mentally disordered persons (within the meaning of the Mental Health Act 1983) 20 years after the last entry in the record or 8 years after death if patient died while in the care of the organisation. NB Specific Learning Difficulty is where a person finds one particular thing difficult but manages well in everything else NB A general learning disability is not a mental illness it is a life-long condition which can vary in degree from mild to profound Royal College of Psychiatrists 34