Clinical Records Management Policy v1.4 201905€¦ · records management and associated risks are...

Version 1.4 July 2018 Page 1 of 41

Trust Policy

Clinical Records Management Policy

Version: 1.4

Role of Policy Lead(s): Head of Information Governance

Role of Executive Lead: Director of Finance (SIRO)

Date Approved by Executive Lead: March 2018

Name of Responsible Committee: Information Governance Committee

Date Approved by Professional Approving Group:

23rd August 2016

Date Approved by Policy Review Group: August 2016

Date Ratified by Hospital Executive Board: October 2016

Date Issued: July 2018

Review Date: October 2019

Target Audience: All Staff

Key Words & Phrases: Caldicott Guardian, Clinical Records, Data Protection Act, Retention Period.

Key Points

The aim of this policy is to define a structure for the Trust to ensure clinical records are maintained, managed and controlled and comply with legal, operational and information needs.

This policy is to ensure consistent management of all the Trust’s clinical records, including the transition from manual to electronic records.

This policy sets out the guidelines for the management of the Trust’s clinical records to

ensure compliance with both the Data Protection Act and the Common Law Duty of Confidentiality.

The policy details the retention periods for all Trust clinical records as detailed in the Department of Health Records Management Code of Practice 2016.


Version Control Sheet

Version Date Policy Lead(s) Status Comment

0.1 09/05/16 Head of Information Governance

Draft Transferred to new format


Draft Changes following presentation at Policy Review Group and HEB


Draft Changes following publication of the Records Management Code of

Practice for Health and Social Care 2016

0.4 August 16 Head of Information Governance

Draft Re-submitted to HEB Sept 2016

1.0 October 16 Head of Information Governance

Final Approved at HEB October 2016

1.2 March 2018

Head of Information Governance

Draft Changes following annual review

1.3 July 2018 Information Governance Final Definitions updated.

1.4 May 2019 Policy & Guidelines manager

Interim Review date amended to show October 2019

Document Location

Document Type Location

Electronic Policy Hub

Related Documents

Document Type Document Name

Electronic Non-Clinical Records Management Policy

Electronic Records Management Strategy

Electronic Transgender Guidance


Contents

Page No

1. Introduction …………………………………………………… 4

2. Scope of the Policy …………………………………………………… 4

3. Definitions …………………………………………………… 5

4. Purpose of the Policy …………………………………………………… 5

5. The Policy …………………………………………………… 5

6. Professional Obligations/Standards …………………………………………………… 6

7. Record Information Quality Assurance

…………………………………………………… 7

8. Trust Clinical Records …………………………………………………… 7

9. Record Creation …………………………………………………… 16

10. Record Management …………………………………………………… 18

11. Records Storage …………………………………………………… 19

12. Records Tracking/Transportation …………………………………………………… 20

13. Record Disclosure …………………………………………………… 22

14. Records Retention …………………………………………………… 22

15. Records Destruction …………………………………………………… 23

16. Record Disposal …………………………………………………… 24

17. Duties / Organisational Structure …………………………………………………… 24

18. Raising Awareness / Implementation / Training

…………………………………………………… 26

19. Monitoring Compliance of Policy …………………………………………………… 26

20. Equality Impact Assessment …………………………………………………… 26

21. References …………………………………………………… 26

Appendix 1: Clinical Records Retention Schedule

…………………………………………………… 28

Appendix 2: List of Clinical Systems ……………………………………………………. 38


1. INTRODUCTION 1.1 Records Management is the process by which an organisation manages all aspects

of records whether internally or externally generated, and in any format or media type, from their creation, all the way through their lifecycle to their eventual disposal.

1.2 The Trust’s clinical records are its clinical memory, providing evidence of actions and decisions relating to patient care and representing a vital asset to support the treatment of patients. Clinical records support and protect the interests of the Trust, the rights of patients, staff and members of the public.

1.3 This policy determines the standards which must be followed when handling and

dealing with any Trust clinical record. 1.4 This Clinical Records policy should be read in conjunction with the Trust’s Records

Management Strategy and the Trust’s Non-Clinical Records Policy. 1.5 Frimley Health NHS Foundation Trust is committed to the provision of a service that

is fair, accessible and meets the needs of all individuals. 1.6 Where it is identified a member of staff is not adhering to the guidelines set out in

this policy, the Trust reserves the right to take disciplinary action. 2. SCOPE OF THE POLICY 2.1 This policy applies to all Trust clinical records, both manual and computerised

including joint health and social care records. 2.2 The main principles of this policy are:

it relates to all clinical records held in any format by the Trust; it applies to information in paper and other physical forms, e.g. electronic, microfilm,

negatives, photographs, audio or video recordings and other assets; it relates to the 5 distinct phases in the life of information; creation, retention,

maintenance, use and disposal; to set out the Trust’s commitment to create, keep and manage clinical records,

including electronic records which document the treatment provided to patients. to define a structure for the Trust to ensure adequate clinical records are

maintained, managed and controlled and comply with legal, operational and information needs.

2.3 Records can be updated and inputted by anyone working within or on behalf of the

Trust. 2.4 This policy sets out a framework within which the staff responsible for managing the

Trust’s clinical records can develop specific policies and procedures to ensure that


all clinical records are managed and controlled effectively and at best value commensurate with legal, operational and information needs.

2.5 This policy will be reviewed every three years (or sooner if new legislation, codes of

practice or national standards are introduced). 3. DEFINITIONS 3.1 A Record is defined as anything which contains information (in any medium) that

has been created or gathered as a result of any aspect of the work of NHS employees, including (but not limited to) bank, agency and locum staff; students; voluntary staff and trainees on temporary placements.

3.2 A Clinical Record is defined as ‘any record which consists of information relating to

the physical or mental health or condition of an individual and has been made by or on behalf of a health professional in connection with the care of that individual’.

3.3 The creation, management, use, retention and destruction of Clinical Records is as

defined in the Data Protection Act (DPA) 2018 and the NHS Records Management Code of Practice.

3.4 Records management - Field of management responsible for the efficient and

systematic control of the creation, receipt, maintenance, use and disposition of records, including processes for capturing and maintaining evidence of and information about business activities and transactions in the form of records.

3.5 Records system - Information system which captures, manages and provides

access to records through time. 4. PURPOSE OF THE POLICY 4.1 The purpose of this policy is to ensure clinical records are managed and controlled

appropriately. This includes how a record is created and kept secure.

4.2 The purpose of the policy is to manage the Trust’s transition from paper to electronic records.

5. THE POLICY

5.1 Legal Obligations

5.1.1 Data Protection Act (DPA) 2018

The Data Protection Act regulates the processing of personal data, held manually and on computer. It applies to all personal information; not just health records. Personal data is defined as data relating to a natural person that enables him/her to be identified either from that data alone or in conjunction with other information in the data controller’s possession. It therefore includes such items as an individual’s name, address, age, race, religion, gender and physical, mental or sexual health.


5.1.2 The Data Protection Act contains 3 key strands:

Accountability and Transparency Compliance with the 6 data protection principles Observing the rights of data subjects

5.1.3 Clinical records management staff have a key role to play in ensuring that records

can be located, retrieved and supplied in a timely manner. 5.2.1 NHS Confidentiality Code of Practice April 2007

This Code of Practice provides guidance to the NHS and related organisations on the handling of confidential patient information across the NHS. Patient information is held under legal and ethical obligations of confidentiality. Information provided in confidence must not be used or disclosed in a form that might identify a patient without his or her consent.

5.2.2 The Confidentiality Code of Practice describes a Confidentiality Model which has 4

key requirements: Protect – look after the patient’s information Inform – ensure patients are aware of how their information is used Provide choice – allow patients to decide whether their information can

be disclosed or used in particular ways Improve – always look for better ways to protect, inform and provide

choice

5.3.1 The Caldicott Principles The 7 Caldicott Principles must be observed when disclosing confidential patient information to any other person either working for the Trust or for another healthcare provider:

1. Justify the purpose 2. Do not use patient identifiable information unless absolutely necessary 3. Use the minimum necessary patient identifiable information 4. Access to patient identifiable information must be on a strict need to know

basis 5. Everyone must be aware of their responsibilities 6. Everyone must understand and comply with the law. 7. Duty to share but can be as important as the duty to protect confidentiality.

6. PROFESSIONAL OBLIGATIONS/STANDARDS

6.1 Profession Obligations 6.1.1 All Trust clinical records must be a legible record which:

Enables the patient to receive effective continuing care Enables the healthcare team to communicate effectively Enables the patient to be identified without risk of error Facilitates the collection of data for research, education and audit Can be used in legal proceedings


6.1.2 The Trust has comprehensive systems in place for the access, storage, retrieval,

usage, retention and destruction of all Trust clinical records. 6.1.3 Clinical record keeping standards are monitored through the clinical audit process. 6.2 NHS Number

The NHS number is the unique identifier for all patient records and is a component of NHS Digital. Use of the NHS number will allow linkage of patient records across systems and organisations. It is envisaged that record linkage will improve effectiveness and efficiency of clinical care to patients and support the concept of a lifelong record.

6.2.1 The Trust is required to ensure all clinical systems contain the NHS number and each system fully adopts the NHS Number in order to be compliant with the National NHS Number Information Standard.

7. RECORD INFORMATION QUALITY ASSURANCE 7.1 Good quality information stored in clinical records enables staff to undertake their

roles and responsibilities effectively as well as provide authentication of the records so that the evidence derived from them is shown to be credible and authoritative.

7.2 When managing its clinical records, the Trust must ensure that the clinical record

being created is of high quality. All clinical records must: Be factual, consistent and accurate Be written in black ink Be written as soon as possible after an event has occurred, providing current

information on the care and condition of the service user Be written clearly, legibly and in such a manner that they cannot be erased Have errors corrected by a single line and any such corrections signed and

dated by the person making the amendment. Erasers, liquid paper, or any other obliterating agents should not be used

Be accurately dated, timed and signed with the signature being printed alongside the first entry

Contain as few abbreviations or jargon as possible Be consecutive Be bound and stored in accordance with Trust’s procedures ensuring that

the likelihood of loss of documentation is minimised 8. TRUST CLINICAL RECORDS 8.1 Trust Clinical Record 8.1.1 A Trust clinical record is created to ensure clinical information relating to a patient is

available at the point of need within the Trust. The purpose of a clinical record is to: Support the care process and continuity of care. Support day-to-day business that underpins delivery of care.


Support evidence based practice. Support sound administrative and managerial decision-making. Meet legal requirements, including requests from service users Assist clinical and other audits. 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.

8.1.2 Whilst the Trust aims to operate a unified clinical record for patient care, historically

the main clinical record was in a manual format. The Trust is going through a transition period of moving from paper to electronic records, so the patient’s full clinical record will be held both in paper and electronic format.

8.1.3 The legacy paper medical records are managed by the Medical Records

Departments at Heatherwood & Wexham and Frimley. The legacy paper medical records are stored in a Medical Records library at Frimley, Heatherwood, Wexham and King Edward VII

8.1.4 In January 2017, the Trust started to implement an Electronic Document

Management Systems (EDMS) which has seen the Trust scan in its legacy paper medical records into Evolve creating an EDMS record for every active patient.

8.1.5 Additionally, the as Trust is scanning records on a day forward scanning approach,

in order to clear the Frimley, Wexham and Heatherwood Medical Record libraries inactive patient records are also being scanned into EDMS.

8.2 Outpatients Records 8.2.1 Any patient who was a new patient to the Trust (never been treated) from January

2017 will not have had a paper medical record created for them. The patient will have an electronic record.

8.2.2 Any patient who was being seen by the Trust from January 2017, for their first/next

follow up appointment, will have had their legacy paper medical records scanned into EDMS.

8.2.3 After the appointment, the day forward paper file will have been sent off site for

scanning, creating a fully electronic record for the patient. Note: the day forward file will not have been sent off site if the patient was

attending the Trust for treatment in the next 7 days. Once the subsequent appointments were attended, the day forward file is be scanned into EDMS.

Note: the project started in January 2017 in Paediatrics and was rolled out to all

specialities by the end of June 2017.


8.2.4 When a patient is being referred back to the Trust, the patient’s legacy paper medical records are pulled and scanned prior to the appointment, with the exceptions for late appointment booking, where the records are scanned after the appointment.

8.3 Inpatient – Elective 8.3.1 During an admission, a day forward file is created for the patient, in which all

paperwork for the admission is collected and filed under the correct tabs and this follows the patient throughout their admission.

8.3.2 Once the patient has been discharged, then day forward file is tided up ensuring the

correct classification sheets are inserted and sent to Medical Records Department to be sent off-site for scanning.

8.3.3 At the point the inpatient day forward folder is sent off-site for scanning, if the

patient had an legacy paper medical records, these are pulled and sent off for scanning.

8.4 Inpatient – Emergency Department (ED) 8.4.1 A paper folder is created in the ED department. Wards are encouraged to request

the legacy paper medical record for the patient, to be kept on the ward for clinical referral/treatment, until the patient has been discharged.

8.4.2 When the patient has been discharged, the paper legacy medical records and the

emergency admission folder are sent off site to be scanned. If the legacy paper medical records have not been pulled, any paper legacy medical records are pulled and sent off-site to be scanned.

Exception: Maternity Records – when a patient first attends the ante natal clinic,

a Frimley (Green) / Wexham (lilac) inpatient folder is created for the patient with a DO NOT SCAN page inserted and this is kept in the maternity department until 2 weeks before the due date, then the day forward file is sent to labour ward.

8.4.4 In the Frimley (Green) / Wexham (lilac) folder is a copy of all information written into

the mother’s hand held maternity folders (Frimley – Blue / Wexham – White), when the patient has been discharged from the Community Midwives, the folders and any old legacy paper medical records will be pulled and sent off for scanning.

Note: Except for the Wexham Maternity records (white folder) which is held on site

at Wexham for 3-6 months before being sent off site for storage, these records are not scanned into EDMS.

8.4.6 The structure of the inpatient day forward record for each site is: Resuscitation & Alerts Correspondence Operation & Procedures Care Pathways


Clinical Notes Results & Reports Drug Charts Nursing records AHP records Safeguarding Mental Health Clinical Trials Social Services

8.4.7 Scanning of Patient Volumes Records

Where a patient has multiple volumes of records, these have been scanned into EDMS. However, where a legal paper medical record is inactive or stored at King Edward Medical Records library it has not been scanned into EDMS. Additionally, a different approach for the scanning of volumes was adopted by Frimley and Wexham. The differences in approach is scanning volumes has been merged, so all volumes of legacy paper medical records will be scanned for every patient.

8.5 Departmental Clinical Records

Some departments within the Trust have created and manage their own clinical record. The clinical records in use across the Trust are:

Patient’s electronic medical record Legacy patient medical record Emergency Department, Frimley and Wexham Anti-Coagulant Department, Frimley Appliances Department, Frimley Maternity, Frimley and Wexham Nursing Records, Wexham Pathology, Frimley and Wexham Private Patients, Frimley and Wexham Radiology, Frimley and Wexham Therapies - Occupational & Physiotherapy, Frimley and Wexham Allied Health Professional records Dietetics Department, Frimley Speech & Language Frimley Psychological Medicine, Frimley Pacing Clinic, Cardiology, Wexham Orthodontics, Wexham Parapet – Breast Clinic (King Edward site)

8.6 Emergency Department Record, Frimley and Wexham 8.6.1 When a patient attends one of the Trust’s Emergency Departments a record will be

created on the department’s computer system (Symphony at Frimley and Patient First (MSS) at Wexham) detailing the care and treatment provided to the patient.


8.6.2 On admission of a patient via the Emergency Department a copy of the Emergency Record is filed in the clinical note section of the day forward file for continuity of care and accompanies the patient to the admitting ward.

8.6.3 Where a patient is not admitted into hospital, a separate emergency record is held

by the Trust.

8.6.4 The Emergency Department sends a Discharge Summary of the patient’s attendance to the patient’s General Practitioner (GP) within 24 hours. The Discharge Summary details:

attendance date presenting complaint investigations diagnosis treatment and follow-up

8.6.5 Following the implementation of the Symphony system in 2011 at Frimley, the Trust

ceased creating manual casualty cards. Old casualty cards are stored at the Trust’s off-site storage facility – for their defined retention period.

8.6.6 Following the implementation of the MSS system in 2012 at Wexham, the Trust

ceased creating manual casualty cards. Old casualty cards were microfilmed/scanned and are kept for their defined retention period in the ED Department.

8.6.7 Both Emergency Department systems are fed from the Trust’s Patient

Administration System – thereby sharing the Trust PMI (Patient Master Index). 8.7 Genito Urinary Medicine (GUM), Frimley 8.7.1 The GUM Service run at Frimley Park Hospital closed in August 2017 and active

patients were transferred to other NHS providers. 8.7.2 When the service was closing, all active patients were written to, to obtain consent

for their records to be transferred to the new service provider. Where the patient consented, their record was transferred to the new provider so is not held by the Trust.

8.7.3 A list of patients who were written to and had not consented to their information to be sent to the new providers is held by the Pharmacy Department.

8.7.4 The records of the inactive GUM patients who were not transferred to the new

provider(s) were boxed up and archived at the Trust’s off site storage location for their defined retention period.

8.7.5 Index books for the patients held off site for all inactive GUM records. 8.7.6 The records of HIV patients were also boxed up and archived at the Trusts off site

storage location for their defined retention period


8.8 Anti-Coagulant Department, Frimley 8.8.1 When a patient attends the Trust’s Anti-Coagulant Department a separate record is

created for the patient detailing the treatment provided and test results.

8.8.2 A copy of the record is held in the Anti-Coagulant Department and is not merged into the Trust’s legacy paper Medical Record. The Trust’s hospital number is allocated to patients’ records held on the Anti-Coagulant department system.

8.8.3 The Anti-Coagulant Records are stored within the department or at the Trust’s off

site storage provider for their defined retention period. 8.9 Appliances Department, Frimley 8.9.1 When a patient is treated by Occupational Therapy staff at Frimley, a separate

electronic clinical record is created for them. Following the implementation of the Tiara system in 2017 they ceased creating manual surgical appliance records.

8.9.2 Tiara is fed from the Trust’s Patient Administration System (PAS) – thereby sharing

the Trust PMI. 8.9.3 Old paper records are stored on site for 3 years. Older records are stored at the

Trust’s off-site storage facility –for their defined retention period. Appliance Department Wexham 8.9.4 When a patient attends the Trust’s Appliances department a separate record will be

created for the patient detailing the treatment provided. 8.9.5 A copy of the record is held in the Appliances department and is not merged into

the Trust’s Medical Record. The Trust’s hospital number is allocated to patients’ records held by the Appliances department.

8.9.6 The Appliances Records are stored within the department or at the Trust’s off site

storage provider for their defined retention period. 8.10 Maternity Records, Frimley and Wexham 8.10.1 Maternity patients have hand-held ante-natal records for the duration of their

pregnancy. Maternity records are contained in a single booklet comprising ante-natal, labour and post-natal records. Investigation results will be filed onto the maternity mount sheet in the handheld record.

8.10.2 During the patient’s pregnancy the Trust’s legacy paper medical record is held in

the Ante-natal Department and is available at all consultations. Cardiotocograph (CTG) results are filed into the standard brown re-sealable envelope available in the Obstetric Department.

8.10.3 At Frimley, at the end of the maternity episode (antenatal , labour and postnatal) the

hand held notes will be sent for scanning into the EDMs system.

8.10.4 At Wexham, the maternity booklet (white) is not amalgamated into the record, it is kept on site separate from the main file for 6 months then sent to external storage


for its defined retention period. However once EDMS is rolled out this will be the same as Frimley.

8.11 Nursing Records, Frimley and Wexham 8.11.1 Nursing records form part of the main clinical record and are filed within the day

forward file at both sites. Whilst a patient is an in-patient, nursing records will be held at the bedside for reference and recording purposes. On patient transfer, nursing records will be securely transported together in the inpatient admission file so that these are easily re-utilised by the receiving ward.

8.11.2 When a patient transfer is planned, observation charts, fluid balance charts (not

currently required as part of on-going clinical management) and investigation results will be secured within inpatient admission file.

8.12 Pathology Records, Frimley and Wexham 8.12.1 Request forms for patients are held in the Pathology department detailing the tests

requested for each patient. 8.13 Private Patients, Frimley and Wexham 8.13.1 When a patient attends the Trust’s private patient suite the main medical record will

be used to record a summary of treatment provided to the patient. Where the private practice is managed by the Trust, these records belong to the Trust.

8.13.2 Where the consultant is delivering care as part of their private practice, more detailed information relating to the patient’s care and treatment will be held by the consultant in their private patient records/files.

8.14 Radiology Records, Frimley and Wexham 8.14.1 Radiology records are managed and stored by the Trust’s Radiology departments. 8.14.2 Frimley implemented electronic x-rays in in 2004 and Wexham in 2007. 8.14.3 The Trust’s PACS systems are linked to the Radiology Information System (RIS)

which is fed from the Trust’s integrated Clinical Environment ( ICE ) System – thereby sharing the Trust’s PMI.

8.14.4 Radiology images are distributed across the Trust wide network and displayed

using a web browser. 8.14.5 Radiology Reports are stored on RIS and are also available as additional

information in PACS and ICE. Information from RIS such as requests, appointments and verified Radiology reports are sent to ICE. Radiology reports appear on the web browser once they are validated (checked) by the author

8.14.6 Radiology reports are also distributed in paper copy to all referrers including GPs. 8.14.7 Following the implementation of the PACS systems the Trust ceased creating

manual x-ray films. At Frimley, there are no manual x-rays films stored in the Trust. Old X-ray films are stored at the Trust’s off-site storage facility for their defined retention period - 3yrs plus current year - except paediatric images that are kept


until the patient is 25. Images that have 'do not destroy' stickers are kept indefinitely.

8.14.7 At Wexham, there are x-rays from 2007 stored on site; these are destroyed

annually but kept for a minimum of 8 years in line with the records retention schedule. There are also x-ray films for Paediatrics and Joints kept on site.

. 8.15 Clinical Trial/Research Records, Frimley and Wexham 8.15.1 Where a patient has consented to participate in a clinical trial/research project, at

Frimley a separate file for the patient will be created and stored by the Principal investigator. At Wexham, the research records are kept in the main patient record.

8.15.2 A note is placed in the patient’s EDMS record indicating the patient is part of a

research project. All records belonging to patients enrolled into clinical trials prospectively will be labelled and contain a section for the storage of clinical information relevant to patient’s trial involvement.

8.16 Therapies – Occupational Therapy, Frimley 8.16.1 When a patient is treated by Occupational Therapy staff at Frimley a separate

electronic clinical record is created for them. Following the implementation of the Tiara system in 2009 the Trust ceased creating manual Occupational Therapy records. All Occupational Therapy Records are stored at the Trust’s off-site storage facility –for their defined retention period.


the Trust PMI. Occupational Therapy, Wexham 8.16.3 The therapy notes are written directly into an OT section of the main record. This

was implemented in 2014, so older separate OT records are stored in hard copies in the OT department.

8.17 Therapies – Physiotherapy 8.17.1 When a patient is treated by the Physiotherapy department at Frimley, an outpatient

physiotherapy referral card is created for them. Clinical information relating to their outpatient treatment is recorded on the physiotherapy card. Physiotherapy treatment provided to an inpatient is recorded in the day forward file.

8.17.2 Once the patient has been discharged from the department, the outpatient

physiotherapy card is stored for a short period of time within the Physiotherapy department before being transferred off site to the Trust’s off-site storage facility for their defined retention period.


the Trust’s PMI – Patient Master Index. 8.17.4 At Wexham, the physiotherapy notes are written directly into the main record during

an inpatient stay and are not stored separately. Outpatient referrals received via ICE or paper/fax and are loaded onto IPM. A paper record is created and all clinical records are captured in this. Once the patient has been discharged from the


department a discharge letter is created and shared via ICE. The clinical paper record is kept for a short time within the department and then is transferred off site to the Trust’s off-site storage facility for their defined retention period.

8.18 Allied Health Professional Records (AHP) 8.18.1 Allied Health Professionals write directly into the day forward file for inpatient and

some Outpatient consultations. Any other documentation is filed within the day forward file on discharge.

8.18.2 Where an AHP has undertaken an assessment in the patient’s home whilst the

patient is an inpatient, this documentation is filed within the day forward file. If care continues on an outpatient basis, regular reports must be made and filed in the day forward file, particularly if there is a change of treatment or on discharge. Reports are addressed to consultants (or other relevant clinical staff) and are filed day forward file by Directorate clerical staff.

8.19 Dietetics Department 8.19.1 When a patient attends the Trust’s Dietetics Department at Frimley, a separate

record will be created for the patient detailing the treatment provided.

8.19.2 A copy of the record is held in the Dietetics Department and is not merged into the Trust’s legacy paper medical records. The Trust’s hospital number is allocated to patients’ records held by the Dietetics department.

8.19.3 The Dietetics Records are stored within the department or at the Trust’s off site

storage provider for their defined retention period. 8.19.4 At Wexham, the therapy notes are written directly into the day forward file and are

not stored separately. 8.20 Speech & Language Therapy Records 8.20.1 When a patient attends the Trust’s Speech & Language Therapy departments, a

separate record will be created for the patient detailing the treatment provided. At Frimley this is an electronic record (Tiara). At Wexham it is a paper record.

8.20.2 The record is held in the Speech & Language Therapy departments and is not

merged into the Trust’s Medical Record. The Trust’s hospital number and NHS number is used for patients’ records held by the Speech & Language Therapy departments.

8.20.3 The Speech & Language Records are stored within the department or at the Trust’s

off-site storage provider for their defined retention period. Speech and Language Therapy paper records are stored within the department. They are sent to offsite storage after one year and stored for the appropriate retention period.

8.20.4 In addition to the Speech and Language Therapy records, Speech and Language

Therapists will write summaries of intervention directly into the patient’s medical record (paper or Evolve) for all patients seen during an inpatient stay.

8.21 Psychological Medicine, Frimley


8.21.1 When a patient attends the Trust’s Psychological Medicine Department a separate record will be created for the patient detailing the treatment provided.

8.21.2 A copy of the record is held in the Psychological Medicine Department and is not

merged into the day forward file. The Trust’s hospital number is allocated to patients’ records held by the Psychological Medicine department.

8.21.3 The Psychological Medicine Records are stored within the department or at the

Trust’s off site storage provider for their defined retention period. 8.22 Pacing Clinic, Cardiology, Wexham 8.22.1 When a patient is treated by the Pacing Clinic in the Cardiology department, a

separate record is created for the patient and held in the department. 8.22.2 A copy of the record is held in the Wexham Pacing Department, Cardiology

department and is not merged into the day forward file. The Trust’s hospital number is allocated to patients’ records held by the Pacing Department.

8.22.3 The Wexham Pacing Department records are stored within the department or at the

Trust’s off site storage provider for their defined retention period. 8.23 Orthodontics, Wexham 8.23.1 When a patient is treated by the Orthodontic Clinic, a separate record is created for

the patient and held in the department. 8.23.2 A copy of the record is held in the Orthodontic Clinic and is not merged into the day

forward file. The Trust’s hospital number is allocated to patients’ records held by the Orthodontic Department.

8.23.3 The Orthodontic Clinic records are stored within the department or at the Trust’s off

site storage provider for their defined retention period. 8.24 Parapet – Breast Clinic (King Edward VII site) 8.24.1 When a patient is treated by the Breast Clinic at Parapet, a separate record is

created for the patient and held in the department. 8.24.2 A copy of the record is held in the Breast Clinic at Parapet and is not merged into

the day forward file. The Trust’s hospital number is allocated to patients’ records held by the Breast Clinic.

9. RECORD CREATION 9.1 Clinical Record Creation 9.1.1 When a patient first attends the Trust, the patient details are entered onto the

PAS/Patient Centre or iPM and this will create an electronic record for the patient, this will become the Patient’s unique hospital number.

9.1.2 Records of all clinical treatment provided to a patient must be recorded within the

patient’s electronic record or the applicable electronic clinical system (see Appendix 2 for the list of the Trust’s Clinical systems) using the unique hospital number to


enable members of staff and their successors to continue the care and treatment of a patient.

9.1.2 A number of departments are able to create new Trust identifier electronic clinical

Record for each new patient, e.g. Emergency Departments, Parkside & Paragon, Paediatrics, Obs & Gynae. .

9.1.3 Where a clinical department creates a record for a patient they must ensure this

record can be linked to the patient’s main hospital number either by the patient’s main hospital number or NHS Number. Each clinical department must develop and maintain procedures relating to the creation of their clinical records.

9.1.4 At the point of creating a clinical record consideration must be given to the lifecycle

of the record and its ultimate destruction, particularly where the record is in electronic format, electronic retention chains will be created within EDMS.

9.2 Temporary Medical Records 9.2.1 As a patient clinical record is primarily electronic, the creation of legacy paper

medical records is now redundant. However, there are still some legacy paper temporary medical records in existence.

9.2.2 At Wexham where a patient has attended for 3 appointments, at the end of each

appointment, the outpatient day forward file has been scanned and search undertaken for the original legacy paper medical records. If after the third appointment, the original legacy paper medical record cannot be located, the temporary legacy paper medical record will be classed as the legacy paper medical folder and sent off-site for scanning.

9.2.4 The Medical Record Department manages and maintains a missing record log. 9.3 Merging of Clinical Records 9.3.1 Where it is identified that there is a duplicate legacy paper medical record, the

records will be merged prior to the record being scanned into EDMS. 9.3.2 Where a patient’s record has been scanned into EDMS, and it is identified that

there are duplicate patient records, these records will be merged electronically by the EDMS Team.

9.3.3 The Data Quality Assurance Teams at each site will merge the electronic record on

iPM or PAS and activity, leaving the legacy paper medical record to be merged by Medical Records staff and the EDMS System Manager or applicable system manager to merge the electronic clinical record.

9.3.4 Where a patient is undergoing gender reassignment, the separation of the patient’s

legacy paper medical records needs to be undertaken in full consultation with the patient, the treating clinicians and the Information Governance Department to ensure the correct separation of the legacy paper medical records and ensure it will not create have an adverse clinical impact on the patient.


9.3.5 The Trust will follow the NHS Gender Reassignment guidance for the creation of a new NHS Number.

10. RECORD MANAGEMENT 10.1 Allergy Recording 10.1.1 Allergies & Adverse Drug Reaction used to form part of the inside cover in the

medical records from 2006. Prior to 2006, details were recorded on the “Patient Alert” sheet in the front of the medical record.

10.1.2 At Wexham, any alerts relating to a patient are recorded on iPM at Wexham or on

Evolve by the treating clinician. 10.2 Copying Letters to Patients 10.2.1 Patients will receive a copy of the letters sent to their GP and other consultants

relating to their care. 10.2.2 Results letters are generally not transmitted to patients as these may contain

information not discussed at consultation. 10.3 Advance Healthcare Decisions 10.3.1 Within the Legacy paper medical records, these were filed at the front of the legacy

paper medical record. 10.3.2 At Wexham, a record was created on iPM indicating the presence of a living will. 10.4 Legacy Paper Medical Records Volumes 10.4.1 Where a legacy paper medical record exceeded the size of 4 inches, a second

volume would be created for the patient. The Trust plans to scan in all legacy paper medical record volumes for both sites.

10.5 Electronic Medical Records Volumes / Files 10.5.1 Where a patient is attending a number of outpatient appointments or inpatient an E

number will be created for each day forward file which has been created. E.g. if the patient is attending a cardiology appointment on Monday, pre-assessment clinic for an inpatient procedure on Tuesday, or a Ante-natal patient, also attending diabetes clinic.

10.6 Maintenance of Day Forward Records 10.6.1 The maintenance of the Trust’s day forward files are the responsibility of all staff

who make use of the record. This includes the correct filing of all loose paperwork relating to the patient’s care and the volumising of a record when it exceeds the required size of 4 inches.

10.7 Management of Dictation Chips 10.7.1 Patient information on dictation chips should be kept to a minimum ie hospital number only or patient name only.


10.7.2 The Trust guidance on use of dictation chips should always be followed when using or transporting dictation chips. 11. RECORDS STORAGE 11.1 Clinical Record Storage 11.1.1 All systems used to store clinical records will ensure the information is kept safe

and secure from unauthorised access whilst allowing maximum accessibility to the information commensurate with its frequency of use.

11.1.2 All paper clinical records will be kept in a secure environment and access will be

restricted to authorised personnel only. 11.1.3 Where a legacy paper medical record is stored outside of the Trust’s medical record

library the record must be stored in a logical order to enable quick and easy retrieval of the medical record e.g. organised by date of clinic, numerically, etc.

11.2 Legacy Paper Medical Records Library 11.2.1 The Trust’s Medical Records Departments operate a restricted closed library

system managed only by designated staff, who are authorised to file and retrieve legacy paper medical records. Restricted access to the library ensures confidentiality; security measures are in place to prevent unauthorised access, and improves legacy paper medical record availability.

11.2.2 Any member of staff requesting a legacy paper medical record must be an

authorised Trust employee. Records requested on an urgent or routine basis will be made available within agreed time limits, urgent requests being acted upon immediately.

11.2.3 Frimley Medical Record Library is open Monday – Friday 8-12pm, Saturday &

Sunday 8 -8, including Bank Holidays, to support emergency retrievals, requests and returns of the Trust’s legacy paper medical records..

11.2.4 Wexham Medical Record library is open Monday to Friday from 7:30am to 5pm.

King Edward library 8-5pm Monday – Friday. 11.2.5 The Medical Records procedure manual details the process Medical Records staff

follow when retrieving legacy paper medical records for staff from the Trust’s Medical Record’s library.

11.3 Urgency Scan of records (legacy and day forward records)

Where there is a legacy paper medical record and this is needed to be scanned into EDMS e.g. Serious Untoward incident, this can be undertaken by liaising with the Medical Records department.

11.4 Storage of Medical Record outside of Medical Record Library 11.4.1 Legacy Paper Medical Records/day forward file must always be kept secure when

left unattended to prevent unauthorised access to the clinical record, e.g., stored in a locked cupboard/room.


11.4.2 Where a legacy paper medical record/day forward file is not located in the Trust’s medical record library, the Emergency Department is able to retrieve the legacy paper medical record from the location in the hospital that they are tracked it to. Master keys for offices and keypad entry at Wexham are available via the Switchboard, A&E staff and the Bed Manager.

11.4 Storage of Medical Records on the wards

Legacy paper Medical Records/day forward file will be stored on the ward either in a medical record trolley behind the Ward desk, or, for surgical patients, at the end of the patient’s bed with their nursing notes.

11.5 Trust Off-site Storage 11.5.1 The Trust’s off-site storage facility – Iron Mountain - is used to stored inactive

clinical records (Pharmacy, Occupational Therapy, Physiotherapy, Emergency Department).

11.5.2 Each department is responsible for ensuring clinical records are stored in line with

the Trust’s Off Site Storage Procedures.

12. RECORDS TRACKING/TRANSPORTATION 12.1 Tracking medical records 12.1.1 The Trust’s legacy paper medical records/day forward files are registered on the

PAS. All record transactions (i.e. movements) relating to a Trust legacy paper medical records must be recorded on the PAS within the “Casenote Tracking module”, this applies for legacy and all e folders.

12.1.2 When a legacy paper Medical Record/day forward file leaves the Trust’s medical

record library it must be tracked to the location it is being moved to. Tracking the movement of all paper clinical records electronically records the movement of the manual medical record/day forward file.

12.1.3 All movements of a legacy paper medical record/day forward file must be tracked

on the PAS as soon as possible and certainly within 15 minutes of the movement. The history of previous record movements will be kept for the last six movements at Frimley. At Wexham the medical record tracking history is kept indefinitely as all transactions since creation are shown in the history section on PDT.

12.1.4 When a record is moved it is the responsibility of the person in the current location

to track the record to its new location. 12.2 Transportation of clinical records within the hospital site 12.2.1 All clinical records being transported must be placed in sealed and accurately

addressed envelopes, marked Private & Confidential and stating the name of the person to whom they are being sent (i.e., it is insufficient to simply address them to a department or building).

12.2.2 When a patient is being transferred within the Hospital building from department to

department by a Trust member of staff (e.g., a porter) the member of staff must carry the clinical record.


12.2.3 When a patient is not escorted by a Trust member of staff the patient could in

exceptional circumstances be asked to carry their clinical records, providing they are in a sealed envelope that is fully addressed to the department/ward the patient is due to visit/attend.

12.2.4 Clinical records must not be left unattended at any time (e.g., when awaiting

Portering services). 12.3 Transportation of clinical records off site 12.3.1 Where clinical records need to be transferred to another locations or hospital sites

to support the Trust services (e.g., for outpatient appointments at off-site clinics - Farnham, Fleet, Aldershot Centre For Health, Bracknell, Chalfont, Brants Bridge, St Marks, King Edwards, Heatherwood, etc.), the transportation of clinical records must be undertaken by Trust transport in sealed envelopes or, in the case of bulk returns, in sealed bags/boxes.

12.3.2 Where clinical records are being transferred to the Trust’s off-site storage facility it

is the responsibility of the off-site storage company to ensure all records are securely transferred in full compliance with the Data Protection Act 2018.

12.3.3 Only where staff need to treat a patient outside of Trust premises (e.g. at home,

nursing home, provision of community services etc.), the member of staff is permitted to transfer the patient’s paper clinical record.

12.3.4 When staff are transporting paper clinical records they must ensure all records are

kept secure during transit (e.g., in the boot of a car and not on a seat) and are never left in a car unattended overnight.

12.3.5 All paper clinical records must be returned to the hospital as soon as possible. 12.3.6 For community staff, any additional documentation that is required for patient care (eg diaries, copies of test results etc) must be kept secure at all time. If diaries are being used, only the minimum amount of information should be recorded to identify the patient ie initial only or hospital number only.

12.4 Removal of a clinical record/patient information from the Trust Premises 12.4.1 A patient’s medical record or any patient information must not be removed from the

Trust premises by individual members of staff unless it is for approved business use (i.e., outpatient appointment at an off-site location, care and treatment of patient in the community/at their home).

12.4.2 Staff are not permitted to take patient information off site unless approval has been

obtained from the Trust’s Medical Records Manager or Deputy or their Line Manager.

12.4.3 Where staff have a business need to transfer records between Trust sites, the

transfer of these records must follow the process in paragraph 12.1.


13. RECORD DISCLOSURE 13.1 Internal Requests for Medical Records Required for Clinical Care 13.1.1 Internal requests for legacy paper medical records from Trust staff must only be for

the purpose of clinical care. Requesters are required to state the purpose for the loan of the legacy paper medical record and Library staff will check this on receipt.

13.1.2 Where a legacy paper medical record needs to be accessed for the non-direct care,

but to support the Trust’s business (i.e., research, audit, complaints, litigation) legacy paper medical records must be requested following the appropriate Trust procedures.

13.2 Release of Medical Records to Other NHS Providers 13.2.1 On receipt of a request to release records to another hospital the Trust will release

the requested information based on implied patient consent. 13.2.2. Requests from GP surgeries for results or discharge documentation must be

directed to the department that initiated the requested information. 13.2.3 Only photocopies of the medical record can be released to another NHS Provider,

allowing retention of the original medical record by the Trust. Any exceptions to this procedure must be agreed with the Medical Records Manager.

13.2.4 Any release of a medical record must be recorded within the case note tracking

module on the PAS by the person responsible for sending the medical record to the requested location/person.

13.3 Release of Medical Records to a Third Party 13.3.1 Where the Trust receives a request for patient information from a Third Party (e.g.,

benefits office, police, insurance company, solicitor etc) it will only be disclosed where the patient has consented to the release of their information, or there is a legal obligation on the Trust to share this information, e.g., Coroner request, adult & children safeguarding

13.3.2 The release of patient information to third parties will be managed in full compliance

with the Data Protection Act 2018, Common Law Duty of Confidentiality and Access to Health Records Act.

13.3.3 Information provided to the Trust from other organisations, e.g., GPs, other NHS

Trusts, will be filed in the day forward file where it relates to the care of the patient. 14. RECORDS RETENTION 14.1 Clinical Record Retention 14.1.1 All Clinical records must be retained for defined periods. This retention period is

calculated from the end of the calendar year following the last entry in the record (e.g., manual file, computer record).


14.1.2 The Trust has adopted the retention periods set out in the NHS Digital Records Management: NHS Code of Practice. Appendix 1 of this policy details the retention periods for all Trust clinical records.

14.1.3 Where a record type is not listed the Trust’s clinical managers will carry out a risk

assessment to decide how long the record is required to be kept for. Attention will be paid to other retention periods for similar record types combined with the risks and benefits of destroying or maintaining the records for a prolonged period of time.

14.1.4 Once a retention period has been decided for a clinical record, this will be approved

by the Trust’s EDMS & Medical Records Committee and incorporated within the retention schedule detailed in Appendix 1 of this policy.

14.1.5 The retention schedule details the minimum retention period for each type of clinical

record. Clinical records (whatever the media) may be retained for longer than the minimum period, however generally records should not be retained for more than 20 years in accordance with the Public Records Act 1958.

14.1.6 The Trust will develop procedures detailing how the Trust undertakes an appraisal

of its records. The appraisal process determines whether records are worthy of permanent archival preservation.

14.1.7 The Trust would undertake the appraisal process in conjunction with the local

approved Place of Deposit. This normally applies to a record where a retention period in excess of 20 years is required (e.g., to be preserved for historical purposes), or for any pre-1948 records. In these cases, the National Archives will be consulted.

14.2 Microfilmed Records, Frimley 14.2.1 Microfiche is a permissible storage medium acceptable to the courts. Microfilming

standards were quality assured to ensure reconstruction of the microfilmed record is possible.

14.2.2 Frimley Medical Record Department microfiched inactive medical records from

1992/3 until 2006. A register of all microfiched records is held on a secure departmental database within the Medical Records Library.

14.3 Scanned Records

The GUM department has scanned their clinical records to CD to maintain the record for the required retention period, enabling the manual records to be destroyed and providing much needed physical storage for the active clinical record.

15. RECORDS DESTRUCTION 15.1 Clinical Record Destruction 15.1.1 Clinical records (including copies) not selected for archival preservation and which

have reached the end of their life will be destroyed in a secure manner. This will be undertaken either on site or by the Trust’s off-site storage company.


15.1.2 In exceptional circumstances clinical records may require permanent preservation – the clinician who is seeking to retain a record must gain approval for permanent preservation from the Medical Director and, if possible, consent from the Data Subject.

15.1.3 If the Caldicott Guardian is in agreement, the clinician must document clearly the

reason for permanent preservation clearly within the medical record. Medical Records required for permanent preservation must be clearly marked “FOR PERMANENT PRESERVATION” on the outside front cover.

15.1.4 The destruction of records is an irreversible act. The normal destruction method

used by the Trust is shredding. 15.1.5 All removable magnetic or optical media containing clinical information must be

returned to the IT department for safe disposal. In addition, any IT equipment scheduled for disposal which contains non-removable storage devices, such as hard disk drives, must also be returned to the IT department.

15.1.6 The hard disk must be formatted or rendered inoperable (e.g., physically destroyed)

and stored securely awaiting disposal by the same means as removable media. In order to dispose of magnetic media, a secure bonded media disposal facility must be employed and a full audit trail of tapes and disks disposed should be maintained by the Informatics Department.

16. RECORD DISPOSAL 16.1 Clinical Record Disposal

All clinical records must be disposed of in line with the Trust’s Confidential Waste Procedures

17. DUTIES / ORGANISATIONAL STRUCTURE 17.1 Chief Executive 17.1.1 The Chief Executive has overall responsibility for records management in the Trust.

As accountable officer, he is responsible for the management of the Trust and for ensuring appropriate mechanisms are in place to support service delivery and continuity. Records management is key to this as it will ensure appropriate, accurate information is available as required.

17.1.1 The Chief Executive has a particular responsibility for ensuring that the Trust

corporately meets its legal responsibilities and for the adoption of internal and external governance requirements.


17.2 Caldicott Guardian 17.2.1 The Trust’s Caldicott Guardian has a particular responsibility for reflecting patients’

interests regarding the use of patient identifiable information. He is responsible for ensuring patient identifiable information is shared in an appropriate and secure manner.

17.3 Medical Director 17.3.1 The Medical Director has Executive responsibility for the management and security

of the Trust’s Clinical Records. 17.4 Head of Nursing and Outpatient Manager, Frimley 17.4.1 The Head of Nursing and Outpatient Manager has the responsibility for the day-to-

day management of the Trust’s Medical Records at Frimley. 17.5 Head of Outpatients/Assistant Head of Operations Wexham 17.5.1 The Head of Performance & Planning has the responsibility for the day-to-day

management of the Trust’s Medical Records at Heatherwood & Wexham.

17.6 EDMS System Manager 17.6.1 The EDMS System manager has the responsibility for day to day management of

the information held in the EDMS system. 17.7 EDMS & Medical Records Committee 17.7.1 The EDMS & Medical Records Committee responsibility to provide overarching

governance and guidance to the medical records function, including EDMS, across all Frimley Health sites.

17.7 EDMS Forms Group 17.7 EDMS Process Redesign Group 17.8 Medical Records Manager 17.8.1 The Medical Records Manager is responsible for the management and

maintenance of the Trust’s legacy paper medical records 17.9 Executive/Clinical Directors, Associate Directors 17.9.1 Executive/Clinical Directors and Associate Directors are responsible for ensuring

that departmental policies and procedures relating to the management of their clinical records comply with this Policy and that risks associated with their clinical record usage are managed and controlled.

17.10 Service Managers, Assistant Service Managers and Departmental Heads 17.10.1 Service Managers, Assistant Service Managers and Departmental Heads are

responsible for ensuring that staff within their Department receive training on this policy and their own departmental clinical records procedures to ensure clinical records management and associated risks are controlled.

17.11 All Staff 17.11.1 All Trust staff, whether clinical or administrative, who create, receive and use

clinical records have records management responsibilities. In particular, all staff


must ensure that they maintain accurate and available clinical records for patients and ensure those records are managed in line with this policy and with any guidance subsequently produced.

17.11.2 All Trust staff are responsible for ensuring the availability, security and

confidentiality of all clinical records they access or handle at all times. 18. RAISING AWARENESS / IMPLEMENTATION / TRAINING

18.1 Staff awareness of their individual responsibilities for the maintenance and protection of the clinical records that they create, use or manage will be raised through the Trust’s induction programme, team meetings, Trust Briefings and other avenues as appropriate.

18.2 The training needs of staff in relation to clinical records management will be

identified so that training can be updated and reinforced as necessary.

18.3 Managers will be responsible for ensuring that all their staff are aware of the Trust’s Clinical Records Management Policy.

18.4 All Trust staff will be made aware of their responsibilities for record-keeping and

record management through generic and specific training programmes and guidance.

19. MONITORING COMPLIANCE OF POLICY 19.1 An audit on the management of the trust’s medical records will be undertaken by

medical records manager’s to monitor compliance with the policy.

20. EQUALITY IMPACT ASSESSMENT

20.1 The users of this policy will take into account their statutory duty to promote equality and human rights and to act lawfully within current equality legislation and guidance.

20.2 This policy has been equality impact assessed and has been shown to have no

adverse impact on any equality group. 20.3 The Trust will continue to monitor its effect and will assess again if negative impact

is identified or at the review date. 21. REFERENCES

Department of Health, 2016 Records Management, NHS Code of Practice Data Protection Act (2018)


NHS Confidentiality Code of Practice April 2007 NHSLA Risk Management Standards for Acute Trusts (2014/15)


APPENDIX 1 - Clinical Records Retention Schedule

Record Type Retention start

Retention period

Action at end of retention period

Notes

1. Care Records with standard retention periods Adult health records not covered by any other section in this schedule

Discharge or patient last seen

8 years Review and if no longer needed destroy

Basic health and social care retention period - check for any other involvements that could extend the retention. All must be reviewed prior to destruction taking into account any serious incident retentions. This includes medical illustration records such as X-rays and scans as well as video and other formats.

Adult social care records End of care or client last seen


Children’s records including midwifery, health visiting and school nursing


25th or 26th

birthday (see Notes)

Review and if no longer needed destroy

Basic health and social care retention requirement is to retain until 25th birthday or if the patient was 17 at the conclusion of the treatment, until their 26th birthday. Check for any other involvements that could extend the retention. All must be reviewed prior to destruction taking into account any serious incident retentions. This includes medical illustration records such as X-rays and scans as well as video and other formats.

Electronic Patient Records System (EPR) NB: The IGA is undertaking further work to refine the rules for record retention and to specify requirements for EPR systems

See Notes See Notes Destroy Where the electronic system has the capacity to destroy records in line with the retention schedule, and where a metadata stub can remain demonstrating that a record has been destroyed, then the Code should be followed in the same way for electronic records as for paper records with a log being kept of the records destroyed. If the system does not have this capacity, then once the records have reached the end of their retention periods they should be inaccessible to users of the system and upon decommissioning, the system (along with audit


trails) should be retained for the retention period of the last entry related to the schedule.

General Dental Services records


10 Years Review and if no longer needed destroy

GP Patient records Death of patient 10 years after death - see Notes for exceptions


If a new provider requests the records, these are transferred to the new provider to continue care. If no request to transfer: � Where the patient does not come back to the practice and the records are not transferred to a new provider the record must be retained for 100 years unless it is known that they have emigrated � Where a patient is known to have emigrated records may be reviewed and destroyed after 10 years � If the patient comes back within the 100 years, the retention reverts to 10 years after death.

Mental Health records Discharge or patient last seen

20 years or 8 years after the patient has died


Covers records made where the person has been cared for under the Mental Health Act 1983 as amended by the Mental Health Act 2007. This includes psychology records. Retention solely for any persons who have been sectioned under the Mental Health Act 1983 must be considerably longer than 20 years where the case may be ongoing. Very mild forms of adult mental health treated in a community setting where a full recovery is made may consider treating as an adult records and keep for 8 years after discharge. All must be reviewed prior to destruction taking into account any serious incident retentions.


Obstetric records, maternity records and antenatal and post natal records



For the purposes of record keeping these records are to be considered as much a record of the child as that of the mother.

2. Care Records with Non-Standard Retention Periods Cancer/Oncology - the oncology records of any patient

Diagnosis of Cancer

30 Years or 8 years after the patient has died

Review and consider transfer to a Place of Deposit

For the purposes of clinical care the diagnosis records of any cancer must be retained in case of future reoccurrence. Where the oncology records are in a main patient file the entire file must be retained. Retention is applicable to primary acute patient record of the cancer diagnosis and treatment only. If this is part of a wider patient record then the entire record may be retained. Any oncology records must be reviewed prior to destruction taking into account any potential long term research value which may require consent or anonymisation of the record.

Contraception, sexual health, Family Planning and Genito-Urinary Medicine (GUM)


8 or 10 years (see Notes)


Basic retention requirement is 8 years unless there is an implant or device inserted, in which case it is 10 years. All must be reviewed prior to destruction taking into account any serious incident retentions. If this is a record of a child, treat as a child record as above.

HFEA records of treatment provided in licenced treatment centres

3, 10, 30, or 50 years


Retention periods are set out in the HFEA guidance at: http://www.hfea.gov.uk/docs/General_directions_0012.pdf

Medical record of a patient with Creutzfeldt-Jakob Disease (CJD)

Diagnosis 30 Years or 8 years after the patient has died


For the purposes of clinical care the diagnosis records of CJD must be retained. Where the CJD records are in a main patient file the entire file must be retained. All must be reviewed prior to destruction taking into account any serious incident retentions.

Record of long term illness or an illness that may reoccur


30 Years or 8 years after the patient has died


Necessary for continuity of clinical care. The primary record of the illness and course of treatment must be kept of a patient where the illness may reoccur or is a life long illness.


3. Pharmacy The IGA are conducting further work to expand this section which will be updated in the near future. As an interim measure you can view a list of Pharmacy records and their associated retention periods and actions by clicking on this link to the NHS East and South East Specialist Pharmacy Services retention schedule. Information relating to controlled drugs

Creation See Notes Review and if no longer needed destroy

NHS England and NHS BSA guidance for controlled drugs can be found at: http://www.nhsbsa.nhs.uk/PrescriptionServices/1120.aspx and https://www.england.nhs.uk/wp-content/uploads/2013/11/som-cont-drugs.pdf The Medicines, Ethics and Practice (MEP) guide can be found at the link (subscription required): http://www.rpharms.com/support/mep.asp Guidance from NHS England is that locally held controlled drugs information should be retained for 7 years. NHS BSA will hold primary data for 20 years and then review. NHS East and South East Specialist Pharmacy Services have prepared pharmacy records guidance including a specialised retention schedule for pharmacy. Please see: http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Reports-Bulletins/Retention-of-pharmacy-records/

Pharmacy prescription records. See also Information relating to controlled drugs.



There will also be an entry in the patient record and a record held by the NHS Business Services Authority. NHS East and South East Specialist Pharmacy Services have prepared pharmacy records guidance including a specialised retention schedule for pharmacy. Please see: http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Reports-Bulletins/Retention-of-pharmacy-records/


4. Pathology Pathology Reports/Information about specimens and samples

Specimen or sample is destroyed

See Notes Review and consider transfer to a Place of Deposit

This Code is concerned with the information about a specimen or sample. The length of storage of the clinical material will drive the length of time the information about it is to be kept. For more details please see: https://www.rcpath.org/resourceLibrary/the-retention-and-storage-of-pathological-records-and-specimens--5th-edition-.html Retention of samples for clinical purposes can be for as long as there is a clinical need to hold the specimen or sample. Reports should be stored on the patient file. It is common for pathologists to hold duplicate reports. For clinical purposes this is 8 years after the patient is discharged for an adult or until a child's 25th birthday whichever is the longer. After 20 years for adult records there must be an appraisal as to the historical importance of the information and a decision made as to whether they should be destroyed of kept for archival value.

5. Event & Transaction Records Blood bank register Creation 30 Years

minimum Review and consider transfer to a Place of Deposit

Clinical Audit Creation 5 years Review and if no longer needed destroy

Chaplaincy records Creation 2 years Review and consider transfer to a Place of Deposit

See also Corporate Governance Records

Clinical Diaries End of the year to which they relate


Diaries of clinical activity & visits must be written up and transferred to the main patient file. If the information is not transferred the diary must be kept for 8 years.


Clinical Protocols Creation 25 years Review and consider transfer to a Place of Deposit

Clinical protocols may have archival value. They may also be routinely captured in clinical governance meetings which may form part of the permanent record (see Corporate Records).

Datasets released by HSCIC under a data sharing agreement

Date specified in the data sharing agreement

Delete with immediate effect

Delete according to HSCIC instruction

http://www.hscic.gov.uk/media/15729/DARS-Data-Sharing-Agreement/pdf/Data_Sharing_Agreement_2015v2%28restricted_editing%29.pdf

Destruction Certificates or Electronic Metadata destruction stub or record of clinical information held on destroyed physical media

Destruction of record or information

20 Years Review and consider transfer to a Place of Deposit

Destruction certificates created by public bodies are not covered by an instrument of retention and if a Place of Deposit or the National Archives do not class them as a record of archival importance they are to be destroyed after 20 years.

Equipment maintenance logs

Decommission-ing of the equipment

11 years Review and consider transfer to a Place of Deposit

General Ophthalmic Services patient records related to NHS financial transactions



GP temporary resident forms

After treatment 2 years Review and if no longer needed destroy

Assumes a copy sent to the responsible GP for inclusion in the primary care record

Inspection of equipment records

Decommission-ing of the equipment


Notifiable disease book Creation 6 years Review and if no longer needed destroy

Operating theatre records End of year to which they relate


If transferred to a Place of Deposit the duty of confidence continues to apply and can only be used for research if the patient has consented or the record is anonymised.

Patient Property Books End of the year to which they relate


Referrals not accepted Date of rejection. 2 years as an ephemeral record


The rejected referral to the service should also be kept on the originating service file.

Requests for funding for care not accepted

Date of rejection 2 years as an



ephemeral record

Screening, including cervical screening, information where no cancer/illness detected is detected

Creation 10 years Review and if no longer needed destroy

Where cancer is detected see 2 Cancer / Oncology. For child screening treat as a child health record and retain until 25th birthday or 10 years after the child has been screened whichever is the longer.

Smoking cessation Closure of 12 week quit period


Transplantation Records Creation 30 Years Review and consider transfer to a Place of Deposit

See guidance at: https://www.hta.gov.uk/codes-practice

Ward handover sheet Date of handover 2 years Review and if no longer needed destroy

This retention relates to the ward. The individual sheets held by staff must be destroyed confidentially at the end of the shift.

6. Telephony Systems & Services (999 phone numbers,111 phone numbers, ambulance, out of hours, single point of contact call centres). Recorded conversation which may later be needed for clinical negligence purpose

Creation 3 Years Review and if no longer needed destroy

The period of time cited by the NHS Litigation Authority is 3 years

Recorded conversation which forms part of the health record

Creation Store as a health record


It is advisable to transfer any relevant information into the main record through transcription or summarisation. Call handlers may perform this task as part of the call. Where it is not possible to transfer clinical information from the recording to the record the recording must be considered as part of the record and be retained accordingly.

The telephony systems record (not recorded conversations)

Creation 1 year Review and if no longer needed destroy

This is the absolute minimum specified to meet the NHS contractual requirement.


7. Births, Deaths & Adoption Records Birth Notification to Child Health

Receipt by Child health department


Treat as a part of the child's health record if not already stored within health record such as the health visiting record.

Birth Registers Creation 2 years Review and actively consider transfer to a Place of Deposit

Where registers of all the births that have taken place in a particular hospital/birth centre exist, these will have archival value and should be retained for 25 years and offered to a Place of Deposit at the end of this retention period. Information is also held in the NHS Birth Notification Service electronic system and by the Office for National Statistics. Other information about a birth must be recorded in the care record.

Body Release Forms Creation 2 years Review and consider transfer to a Place of Deposit

Death - cause of death certificate counterfoil

Creation 2 years Review and consider transfer to a Place of Deposit

Death register information sent to General Registry Office on monthly basis

Creation 2 years Review and consider transfer to a Place of Deposit

A full dataset is available from the Office for National Statistics.

Local Authority Adoption Record (normally held by the Local Authority children's services)

Creation 100 years from the date of the adoption order


The primary record of the adoption process is held by the local authority children's service responsible for the adoption service.

Mortuary Records of deceased

End of year to which they relate


Mortuary Register Creation 10 Years Review and consider transfer to a Place of Deposit

NHS Medicals for Adoption Records

Creation 8 years or 25th birthday


The health reports will feed into the primary record held by the local authority children’s services. This means that the adoption records held in the NHS relate to reports that are already kept in another file which is kept for 100 years by the


appropriate agency and local authority.

Post Mortem Records Creation 10 years Review and if no longer needed destroy

The primary post mortem file will be maintained by the coroner. The coroner will retain the post mortem file including the report. Local records of post mortem will not need to be kept for the same extended time.

8. Clinical Trials & Research For clinical trials record retention please see the MHRC guidance at https://www.gov.uk/guidance/good-clinical-practice-for-clinical-trials Advanced Medical Therapy Research Master File

Closure of research

30 years Review and consider transfer to a Place of Deposit

See guidance at: https://www.gov.uk/guidance/advanced-therapy-medicinal-products-regulation-and-licensing

Clinical Trials Master File of a trial authorised under the European portal under Regulation (EU) No 536/2014

Closure of trial 25 years Review and consider transfer to a Place of Deposit

For details please see: http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=uriserv:OJ.L_.2014.158.01.0001.01.ENG

European Commission Authorisation (certificate or letter) to enable marketing and sale within the EU member states area

Closure of trial 15 years Review and consider transfer to a Place of Deposit

For details please see: http://ec.europa.eu/health/files/eudralex/vol-2/a/vol2a_chap1_2013-06_en.pdf

Research data sets End of research Not more than 20 years


For details please see: http://tools.jiscinfonet.ac.uk/downloads/bcs-rrs/managing-research-records.pdf

Research Ethics Committee’s documentation for research proposal

End of research 5 years Review and consider transfer to a Place of Deposit

For details please see: http://www.hra.nhs.uk/resources/research-legislation-and-governance/governance-arrangements-for-research-ethics-committees/ Data must be held for sufficient time to allow any questions about the research to be answered. Depending on the type of research the data may not need to be kept once the purpose has expired. For example data used for passing an


academic exam may be destroyed once the exam has been passed and there is no further academic need to hold the data. For more significant research a Place of Deposit may be interested in holding the research. It is best practice to consider this at the outset of research as orphaned personal data can inadvertently cause a data breach.

Research Ethics Committee’s minutes and papers

Year to which they relate

Before 20 years but as soon as practically possible


Committee papers must be transferred to a Place of Deposit as a public record: http://www.hra.nhs.uk/resources/research-legislation-and-governance/governance-arrangements-for-research-ethics-committees/


APPENDIX 2 – LIST OF FRIMLEY TRUST CLINICAL SYSTEMS

Directorate Department Name of System

Diagnostic & Therapy Services Anticoagulant Coaguchek XS Plus Medicine & ED Endocrinology accu check 360

General/Specialist Surgery Theatres Appeon

General/Specialist Surgery Audiology AuditBase (ROYAL SURREY) Women's & Children Neo-Natal Badger System/SEND Diagnostic & Therapy Services Anticoagulant RAID

Diagnostic & Therapy Services Haematology Haemodynamics

Medicine & ED Pharmacy BlueTeq

General/Specialist Surgery Theatres Care Suite / PISCES

Medicine & ED Clinical InvestigationCarefusion Lung Function (replacement of Breeze database)

Diagnostic & Therapy Services Microbiology Kiestra

Diagnostic & Therapy Services Nutrition and Dietetics Nutritics

Finance & Strategy IM&T Clinical Portal

Women's & Children Maternity Colposcopy

Diagnostic & Therapy Services Pathology Conworx

Diagnostic & Therapy Services Pathology DARTGeneral/Specialist Surgery Vascular Cydar

Medicine & ED Diabetic Clinic Diabeta3

Director of Operations Outpatients DR DoctorMedicine & ED Respiratory Encore Anywhere Women's & Children Maternity Euroking/CTG Monitoring General/Specialist Surgery Urology Ezzee Peezee

General/Specialist Surgery Ophthalmology Heidelburg

Diagnostic & Therapy Services Pathology Labcomm PMIP

General/Specialist Surgery Ophthalmology Humphrey Visual Field Analyser

Medicine & ED Clinical Investigation Hypertension

General/Specialist Surgery Cancer IBIS-II

Medicine & ED Neurology Imed Database

Diagnostic & Therapy Services Pathology MBT-RTC

Diagnostic & Therapy Services Pathology Medifact Cytology Results to PCA

Medicine & ED Pharmacy JAC

General/Specialist Surgery OrthopaedicsJoint Replacement - orthopaedics (Orthoview)

Women's & Children Maternity K2 Fetal Monitoring Training System

Medicine & ED Clinical Investigation Latitude (Boston Scientific) Medicine & ED Cardiology Lifenet

Medicine & ED GUM Lillie

Women's & Children Neo-Natal Massiimo

Diagnostic & Therapy Services Pathology QCM3 Point of Care Diagnostic & Therapy Services Pathology Qpoint

Medicine & ED Cardiology McKesson (previously Medcon)


Medicine & ED Emergency Department Medex/Surgex/Childex

Diagnostic & Therapy Services Pathology Radiance Point of Care Diagnostic & Therapy Services Pathology Sunquest ICE

General/Specialist Surgery Ophthalmology Medisoft

Medicine & ED Cardiology Medtronic

Medicine & ED Clinical Investigation Medtronic Pacemaker Monitoring Tool

Medicine & ED Clinical Investigation Merlin Medical

General/Specialist Surgery Surgery MIME

Medicine & ED Neurology MSDialog

Diagnostic & Therapy Services Pathology Winpath/Ward Enquiry Medicine & ED Clinical Investigation Novacor RTSoft

Diagnostic & Therapy Services Radiology Carestream (Pacs) General/Specialist Surgery Ophthalmology OPTOS

Diagnostic & Therapy Services Radiology Carestream (RIS) Finance & Strategy IM&T PAS/Patient Centre Medicine & ED Clinical Investigation Pathfinder

Medicine & ED Cardiology PRISM (prismnet) Diagnostic & Therapy Services Radiology CT Scanners

Nursing & Quality Risk Management Real Time

General/Specialist Surgery Cancer Somerset Cancer Registry

General/Specialist Surgery Sterile Services (HSDU) SSDMan

Medicine & ED Emergency Department Symphony

Diagnostic & Therapy Services Radiology RIS Archive

Finance & Strategy IM&T Telestroke

Diagnostic & Therapy Services Radiology TMC (Telemedicine Clinic) Diagnostic & Therapy Services Stroke Biometrics

Diagnostic & Therapy Services Therapies Tiara9

General/Specialist Surgery Endoscopy Unisoft/Endocott

General/Specialist Surgery Urology Urodynamics

Women's & Children Neo-Natal Viewpoint

General/Specialist Surgery Theatres Ward Watcher

Medicine & ED Cardiology XIMS


APPENDIX 2 – LIST OF HEATHERWOOD & WEXHAM TRUST CLINICAL SYSTEMS

Directorate Department Name of System

General/Specialist Surgery Urology API BioMerieux

Medicine & ED Haematology ARIA (Oxford system) Women's & Children Maternity Astraia

Women's & Children Neo-Natal Badger System/SEND Diagnostic & Therapy Services Anticoagulant RAID

Medicine & ED Pharmacy Bedford Pharmacy

Medicine & ED Respiratory Care Fusion (Replacement of Lung Function)

Medicine & ED Cardiology CarelinkDiagnostic & Therapy Services Nutrition and Dietetics Abbott Nutrition Hospital2Home E-/registration

Women's & Children Maternity CMISDiagnostic & Therapy Services Pathology Blood Gas Analyser

Women's & Children Maternity Colposcopy Diagnostic & Therapy Services Pathology Blood TrackDiagnostic & Therapy Services Pathology CV5

Medicine & ED Rheumatology DAWN

Women's & Children Paediatrics Diamond

Medicine & ED

Oral Surgery and Orthodontics Consultant Dolphin3D

Director of Operations Outpatients DR Doctor

Finance & Strategy IM&T ICEDiagnostic & Therapy Services Pathology Labcomm PMIP

National System Radiology Image Exchange Portal (IEP) Finance & Strategy IM&T iPM (PAS)

Director of Operations Theatres IQ Utopia

Medicine & ED Cardiology Latitude

General/Specialist Surgery Theatres MetaVision

Finance & Strategy IM&T Mirth ED

Women's & Children Maternity Mosos (CTG)

Medicine & ED Medical MyMeriam

Women's & Children Paediatrics OpenWardDiagnostic & Therapy Services Radiology CRIS

Medicine & ED Emergency Department Patient FirstDiagnostic & Therapy Services Radiology HEIS Diagnostic & Therapy Services Radiology Medcon Diagnostic & Therapy Services Radiology Medica


Director of Operations IM&T Real TimeDiagnostic & Therapy Services Radiology PACS

Director of Operations Stroke Stroke System (Capture stroke) Medicine & ED Cardiology TomCat

General/Specialist Surgery Orthopaedics TraumaCad

Women's & Children Paediatrics Twinkle

General/Specialist Surgery Endoscopy Unisoft

General/Specialist Surgery Theatres Ward Watcher

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