By Sam Dixon, BSHAA member
“From a clinical perspective, there are regulations that state we should keep patient records for a minimum of 8 years since their last visit.https://www.nhsx.nhs.uk/media/documents/NHSX_Records_Management_CoP_V7.pdf(England & Wales)
(Northern Ireland) https://www.health-ni.gov.uk/topics/good-management-good-recordsIf a patient has been active for over 8 years and is still active within the 8 year period, we should keep the full clinical record accessible as it would contain information that might be important to clinical decision making (i.e. don’t archive or delete stuff just because it is over 8 years old). Information on the management of records when the minimum retention period is reached can be found in section 5.2 here https://www.nhsx.nhs.uk/information-governance/guidance/records-management-code/records-management-code-of-practice-2021/#section-2-records-management-obligations
There is a section called “Destruction of digital records” which needs to be looked at too.
Some businesses provide industrial hearing screening for patients. Where this is the case, NHS Digital advises that confidential Occupational Health records should be kept as long as the employee is in employment plus 6 years or until their 75th birthday, whichever comes first. https://www.nhsx.nhs.uk/information-governance/guidance/records-management-code/The maximum retention schedule in https://www.nhsx.nhs.uk/information-governance/guidance/records-management-code/records-management-code-of-practice-2021/#appendix-ii-retention-schedule goes up to 20 years. ROI guidance can be found here https://www.hse.ie/eng/about/who/qualityandpatientsafety/safepatientcare/healthrecordsmgt/
Page 11 of https://www.hse.ie/eng/about/who/qid/quality-and-patient-safety-documents/code.pdf states “Retain for the period of time appropriate to the patient/specialty, e.g. children’s records should be retained as per the retention period for the records of children and young people; mentally disordered persons (within the meaning of the Mental Health Acts 1945 to 2001) 20 years after the last entry in the record or 8 years after the patient’s death if the patient died while in the care of the organization”
This means if we are treating “mentally disordered” patients, we should retain them for 20 years after the last entry.
From a clinical perspective, if a patient has not been active for 8 years, the record should be archived and not deleted so it is not readily available to users on the frontend of any system. We would recommend this in case there is ever a need to access historic information (which may be the case in HCPC fitness to practice cases. The HCPC will investigate as far back as they feel they need to if it is required for a case).
The deletion policy should take rules around “mentally disordered” patients and occupational health into consideration.It is likely we will be unable to tell what records relate to industrial testing or patients who fall into the “mentally disordered” category so records should remain in the secure archive until the patient is 75 years old and it has been at least 20 years after the last entry to ensure we remain compliant with NHS regulations.
Records should then be deleted in line with the agreed deletion policy and the system should keep records of what has been deleted.
Financial records (quite separately) should be maintained for a period of 7 years.
POLICY/ Further notes
We should all also have a data retention policy that clearly states how long we keep data for, when records are archived when records are destroyed, how records of archived and destroyed records are kept, and how “right to be forgotten” requests are managed.