Retention of health records How long should patient medical records be kept retained? Here we set out tables of types of records and the length of time they should be kept according to national guidance on NHS records management.
Although this guidance refers to minimum periods for which records must be retained, there may be times when records need to be kept for longer.
Bear in mind that one of the key principles of the GDPR prohibits the retention of personal data for longer than is necessary.
Records Management Process Advice
Where the system has the capacity to destroy records in line with the retention schedule, and where a metadata stub can remain, demonstrating the destruction, then the Code should be followed in the same way for digital as well as paper records with a log kept of destruction. If the EPR does not have this capacity, then once records reach the end of their retention period, they should be made inaccessible to system users upon decommissioning. The system (along with the audit trails) should be retained for the retention period of the last entry related to the schedule.
When decommissioned retain in accessible format, including the Audit Trail, for a period to be determined by the Data Controller in consultation with Clinical Specialists.
Records should be maintained, deleted or “put beyond use” (in line with the ICO’s guidance “Deleting Personal Data”) in accordance with a regular (at least five years) risk assessment by the Data Controller (or Joint Data Controllers). The risk assessment should be formally recorded and measured against the extant Data Protection legislation and Codes of Practice and the need to ensure effective ongoing clinical care.
Retention Of Medical Records: A Short Guide
Maternity records (including all obstetric and midwifery records, including those of episodes of maternity care that end in stillbirth or where the child later dies)
Retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment, or 8 years after death.
Until the patient's 25th birthday, or 26th if an entry was made when the young person was 17; or 3 years after death of the patient if sooner.
Medical Records Storage
Or 3 years after the death of the patient if sooner and the patient died while in the care of the organisation.This guidance has been reviewed by the Health and Care Information Governance Panel, including the Information Commissioner’s Office (ICO) and National Data Guardian (NDG).
The Records Management Code of Practice 2021 provides guidance on how to keep records, including how long to keep different types of records. It replaces previous versions.
Records come in different shapes and sizes. For example, a record may be a letter on paper, an email, a photograph, an X-ray, a text message, or even a plaster mould.
Health And Safety Records Retention
To help ensure that these records are all managed consistently across England, we publish a Records Management Code of Practice. This provides important information to those responsible for managing records. It includes guidance on topics such as what the law says about managing records, how to file and store records and how long records should be kept for.
Different records are kept for different lengths of time. Most records are destroyed after a certain period of time. Generally most health and care records are kept for eight years after your last treatment. GP records are kept for much longer. However this is being reviewed to ensure they are not kept for longer than necessary once you have left your GP practice (for example if you moved abroad or died). Some records are considered valuable in the longer term, for example for research. They can also enable the public to understand how an organisation worked in years to come. This includes records such as patient surveys.
You have a right to obtain a copy of your personal data. This is commonly referred to as subject access. You can obtain a copy of your personal data by making a Subject Access Request.
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Everyone within a health and care organisation is responsible for managing records appropriately. It is therefore important that you understand how records should be managed - how records are created, maintained and disposed of appropriately.
The Records Management Code of Practice provides a framework for consistent and effective records management based on established standards. It covers organisations working within, or under contract to, the NHS in England. The code also applies to adult social care and public health functions commissioned or delivered by local authorities.
It includes topics such as legal, professional, organisational and individual responsibilities when managing records. It also provides guidance on the storage, retention and deletion of records. Different types of records should be kept for different amounts of time and the Records Management Code includes a retention schedule which sets out how long each type of record should be kept.
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The code is mainly written for those who are designated as responsible for records management within your organisation. This may be a records manager in a trust, a practice manager in a GP surgery or the person who has responsibility for records management in their role at a local authority. However even if this is not a core part of your role, as someone who works in a health and care organisation you should ensure the following:
The Records Management Code of Practice is an important document for records managers working in the NHS and adult social care and should be used as a basis for your own organisation’s records management policy. It covers:
Your organisation should have a designated member of staff of appropriate seniority (for example care home manager or practice manager) who leads on records management. This role should be formally acknowledged and communicated throughout the organisation. Sometimes this role is part of the information governance team. If you have any record management responsibilities it is important that you read the Records Management Code of Practice and apply the guidance in your organisation. Each organisation must have an overall policy statement on how it manages all of its records. This statement must be endorsed by the operational management team, board (or equivalent), and made available to all staff at induction and through regular updates and training.
Improving Staff Retention
It is also important to note that there are currently a number of ongoing inquiries including the Independent Inquiry into Historic Child Sex Abuse and the Infected Blood Public Inquiry. This means that records must not be destroyed until guidance is issued by the relevant inquiry. Future inquiries may lead to specific records management requirements. If that happens we will publish additional guidance on our website.Sincetraveling around the UK lecturing on the General Data Protection Regulations and how they’re affecting dentists and dental patient records when they came into force on 25
In this dental bulletin we will look at the current legal guidelines before GDPR and attempt to clear up any confusion regarding the retention and value of dental patient records.
Records created by NHS authorities, including NHS dentists, fall within the scope of the Public Records Act 1958 and the Freedom of Information Act 2000. These impose a statutory duty of care directly on individuals who have direct responsibility for such records.
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In January 2009 the Department of Health published a document entitled “Records Management, NHS Code of Practice, Part 2”. This document stated that NHS records can in certain circumstances be kept up to a maximum of 30 years. It also set out the minimum retention periods for which the various records created within the NHS should be retained. Under Appendix D1 it stated that community (i.e. non hospital) dental records should be retained for a minimum of 11 years for adults and for children 11 years or up to their 25
However in July 2016 that guidance was withdrawn by the Information Governance Alliance on behalf of the Department of Health. The current rules relating to the retention of patients’ notes is in fact set out in the Records Management Code of Practice for Health and Social Care 2016.
These guidelines state that records should be created, controlled and processed in accordance with the purpose for which the data was originally obtained, i.e. for the purpose of providing dental treatment or care. Records should be retained “in line with NHS recommended Retention Schedule”. This states that general Dental Services records should be retained for a minimum period of 10 years from the date of discharge of the patient from the practice or when the patient was last seen. There is no 30 year recommendation. At the 10 year point, there should be an appraisal to determine whether the records should be retained for a further period or deleted.
Record Keeping Guidance
Practices should have an internal policy regarding the appraisal, retention or destruction of dental patient records. No records should be automatically destroyed. However, a practice should consider the purpose for retaining the records; examples of this could be an ongoing legal case or that they are the subject of research. It isn’t appropriate to adopt a blanket “err on the side of caution” approach and retain all dental records indefinitely.
Indeed Article 5 of the GDPR sets out the guiding principles relating to the processing of personal data (including medical records).
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