These records are patient focused increasingly multi-disciplinary in nature, and could be created by any Health Care Professional for example, nusing, medicine or allied health professional working either in community or acute settings.
A patient record is a collection of documents that provide an account of each episode in a patient's clinical history where they visited, sought treatment, or received care.
|
Ref |
Record Type |
Minimum |
Revelant Legislation/ |
Final Action |
|---|---|---|---|---|
|
G |
Drop in centre contact sheet |
The records should be kept as per the period of time appropriate to the patient speciality for example, children's records see GMGR G19 |
As per the final action for the appropriate patient speciality |
|
|
G1 |
Abortion |
Records to be maintained within the primary or secondary patient care record and retained for the period of time appropriate to that record |
|
Destroy |
|
G2 |
Accident and Emergency |
|
|
|
|
|
A&E records (where these are stored seperately from the main patient record) |
Retain for the period of time appropriate to the patient/speciality for example, children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
Destroy See GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
|
Accident and emergency registers |
eight years after the year to which they relate |
|
Determined on review |
|
G3 |
Admission books |
eight years after last entry |
|
Destroy |
|
G4 |
Ambulance records - patient identifiable component (including paramedic records made on behalf of the Ambulance Service) |
10 years (applies to ALL ambulance clinical records) |
|
Destroy |
|
G5 |
Angiography tapes and disks |
eight years |
|
Destroy |
|
G6 |
Asylum seekers and refugees |
Retain for the period of time appropriate to the patient/speciality for example, children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
Destroy |
|
G7 |
Audio tapes of calls requesting care |
Retain taped calls for three years providing all relevant clinical information has been transferred to the appropriate patient record. |
Destroy |
|
|
G8 |
Audiology records |
Retain for the period of time appropriate to the patient/speciality for example, children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
Destroy See GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
|
G9 |
Audit trails (electronic health records) see also G51 |
Organisations are advised to retain all audit trails until further notice |
|
Destroy |
|
G10 See AD-019 |
Birth notification (to child health department) |
Retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment, or eight years after death |
|
Destroy |
|
G11 See AD-019 |
Birth notification sheets |
10 years |
|
Special review by PRONI |
|
G12 |
Birth registers (That is; register of births kept by the hospital) |
Lists sent to GRO on a monthly basis. One year. |
|
Determined on review |
|
G13 |
Body release forms maintained as part of the patient record |
Retain for the period of time appropriate to the patient/speciality for example, children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
A per the final action for the patient record |
|
G14 |
Cervical screening sliders |
10 years |
|
Destroy |
|
G15 |
Chaplaincy records |
three months |
|
Destroy |
|
|
Baptismal, blessing, naming records, memorials cards/books |
75 years |
|
Transfer to PRONI |
|
G16 |
Child and family guidance |
Retain for the period of time appropriate to the patient/speciality for example, children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
Destroy See GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
G17 |
Child health records (notification of visitors/new entrants either from abroad or from within the UK from airports, the Home Officer Immigration Centre and the Housing Executive) |
Database of notification is recorded on both NIMATs and the CHS |
|
Destroy |
|
G18 |
Child health system - electronic system record |
100 years |
|
Determined on review after consultation with Trust professional and records management staff |
|
G19 See AD-019 |
Children and young people (health records) including school health records but see GMGR Section G78 for children's oncology record |
See AD-009 Until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment or eight years after last entry, if longer, or eight years after death if death occurred before 18th birthday. |
|
Determined on review after consultation with Trust professional and records management staff |
|
G20 |
Clinical audit records |
five years |
|
Destroy |
|
G21 |
Clinical protocol (GP, in-house) |
25 years |
|
Destroy |
|
G22 |
Clinical psychology |
20 years |
|
Destroy |
|
G23 |
Consent forms |
Retain as part of patient clinical record |
|
Destroy |
|
G24 |
Contraception and sexual health records |
See family planning GMGR Section G45 |
|
Destroy |
|
G25 |
Crash trolleys - record that a check on the trolley has been completed and any subsequent action |
See AM-003 |
|
Destroy |
|
G26 |
Death registers (iThat is; register of deaths kept by the hospital) |
Lists sent to GRO on a monthly basis two years |
|
Destroy |
|
G27 |
Discharge books (that is; register of those discharged by the hospital) |
eight years after last entry |
|
Determined on reivew |
|
G28 |
DNA (health records for patients who did not attend for appointments as out-patients |
Where there is a letter or correspondence informing the healthcare professional/ organisation that has referred the client/patient/service user that the person did not attend and that no further appointment has been given, retain for two years after the decision is made. Where there is no letter or correspondence informing the healthcare professional/ organisation that has referred the client/patient/service user that the person did not attend and that no further appointment has been given, retain for the period of time appropriate to the patient/speciality |
|
Destroy See GMGR Section G19 for children's records and GMGR Section G68 for mentally disordered persons' records |
|
G29 |
Death certificate stubs |
one year from the last stub |
|
Destroy |
|
G30 |
Dental, and orthodontic records |
|
|
|
|
|
Community dental service |
11 years Until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment or 11 years after last entry, if longer, or eight years after death if death occurred before 18th birthday |
|
Destroy |
|
|
Hospital dental records |
|
|
|
|
|
Adults |
eight years |
|
Determined on review after consultation with Trust dental and records management staff |
|
|
Children |
Children and young people - retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment or eight years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice or clinicians should be sought as to whether to retain the records for a longer period |
|
Determined on review after consultation with Trust dental and records management staff |
|
G31 |
Dental records of a serving prisoner |
11 years after release |
|
Destroy |
|
G32 |
General dental services patient records |
six years |
Destroy |
|
|
G33 |
Orthodontic records |
six years |
Destroy |
|
|
G34 |
Dental and epidemiological surveys |
Review after 30 years |
|
Determined |
|
G35 |
De-registered patients records |
Records for de-registered patients, which are received by the HSCB, should be retained for at least 10 years. After the retention period has elapsed a decision must be taken by the HSCB as to whether to destroy the records or retain them further |
|
Destroy |
|
G36 |
Diagnostic image data (for diagnostic imaging undertaken in the private sector under contract to the HSC or private providers treating patients on behalf of the HSC) |
Retain for the life of the National Diagnositc Imaging Services contract and then return the data to the HSC after which the retention period in this retention schedule will apply |
National Diagnostic Imaging Services contract, records mangement, NHS code of practice |
Destroy |
|
G37 |
District nursing records |
Retain for the period of time appropriate to the patient/speciality for example, children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
Destroy See GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
G38 |
Discharge nursing team assessments of patients' homes and nursing homes |
Retain for the period of time appropriate to the patient/speciality eg children's records see GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
Destroy See GMGR Section G19, for mentally disordered person see GMGR Section G68 |
|
G39 |
Donor breast milk bank |
|
|
|
|
|
Donor milk batch |
30 years |
Destroy |
|
|
|
Donor milk used |
30 years |
Destroy |
|
|
G40 |
Donor records (blood and tissue) |
30 years post transplantation See also Pathology GMGR Section 'K' See GMGR Section G97 for records of patients who receive an organ transplant |
Advisory Committe on the Safety of Blood, Tissues and Organs (SaBTO) |
Destroy |
|
G41 |
Drug trials, records |
See GMGR Section J67 and GMGR Section J58 |
|
See GMGR Section J57 and GMGR Section J58 |
|
G42 |
Duplicate patient record notification forms |
two years after the decision of whether or not to merge unless there is a business need to retain for longer |
|
Destroy |
|
G43 |
Electrocardiogram (ECG) records |
eight years Each chart should be labelled with the patient's name and unique identifier. Any over-sized charts could then be stored seperately where a report is written into the health records |
|
Destroy |
|
G44 |
Endoscopy records including: Sterlix endoscopic disinfector traceability strips, traceability stickers for PEG/stents (endoscopy) |
Retain for standard retention periods ie 8 years for adults and in the care of children and young people retain until the patient's 25th birthday or 26th if young person was 17 at conclusion of treatment, or eight years after death. If the illness or death could have potential relevance to adult conditions or have genetic implications, the advice of clinicians should be sought as to whether to retain the records for a longer period |
|
Destroy |
|
G45 |
Family planning (also contraception and sexual health records) |
For records of adults - retain for 10 years after last entry. For clients under 18 - retain until 25th birthday or for 10 years after last entry, whichever is the longer ie records for clients ages 16-17 should be retained for 10 years and records for clients under 16 should be retained until age 25 (That is, still retained for at least 10 years) Records of deceased person should be retained for eight years after death |
Clinical Standards Committee Faculty of Sexual and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists NB The longest license period for a contraceptive device is 10 years |
Determined on review after consultation with Trust medical and records management staff |
|
G46 |
Forensic medicine records (including pathology, toxicology, haematology, dentistry, DNA testing, post mortems forming part of the Coroner's report, and human tissue kept as part of the forensic record) See also human tissue see GMGR Section G56, postmortem reports see GMGR Section K43 |
For post-mortem records which form part of the Coroner's report, approval should be sought from the coronoer for a copy of the report to be incorporated in the patient's notes, which should then be kept in line with the speciality, and then reviewed. All other records retain for 30 years. |
The Retention and Storage of Pathological Records and Archives (3rd edition 2005) guidance from the Royal College of Pathologists and the Institute of Biomedical Science: |
Destroy |
|
G47 |
Genetic records |
30 years from date of last attendance |
The Royal College of Pathologists endorses the Code of Practice on Genetic Testing (1997) and its recommendations on storage, archiving and disposal of specimens and records relate to human testing services (genetics) offered and supplied direct to the public. Those who intend to offer such services should follow its guidance. |
Destroy |
|
G48 |
Genito Urinary Medicine (GUM) Includes sexual health records |
For records of adults - retain for 10 years after last entry For clients under 18 - retain until 25th birthday or for 10 years after last entry, whichever is the longer (That is, records) for clients ages 17-17 should be retained for 10 years and records for clients under 16 should be retained until age 25 (That is; still retained for at least 10 years). Records of deceased persons should be retained for eight years after death |
Clinical Standards Committee, Faculty of Sexual and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists |
Destroy |
|
G49 |
GP Medical Records |
GP Medical Records should be returned to the HSCB when:
GP Records should be held by the HSCB other than the records listed below for 10 years after death or after the patient has permanently left the country unless the patient remains in the European Union. |
Destroy |
|
|
|
GP medical records - maternity records |
25 years after last live birth |
Destroy |
|
|
|
GP medical records - records relating to person receiving treatment for a mental disorder within the meaning of the Mental Health (NI) Order 1986 |
20 years after the dat of the last contact or 10 years after patient's death if sooner GPs may wish to keep mental health records for up to 30 years before review. They must be kept as complete records for the first 20 years but records may then be summarised and kept in summary format for the additional 10 year period |
Destroy |
|
|
G50 |
GP medical records, relating to HM Armed Forces. This refers to GP records of serving military personnel that were inexistence prior to them enlisting |
GP Medical Records should be returned to the HSCB when a patient becomes a member of HM Armed Forces. The medical records should be marked “not for destruction” within the HSCB. The Ministry of Defence (MoD) retains a copy of the records relating to service medical history. The patient may request a copy of these under the Data Protection Act (DPA), and may, if they choose, give them to their GP. GPs should also receive summary records when ex-Service personnel register with them. What GPs do with them then is a matter for their professional judgement, taking into account clinical need and DPA requirements – they should not, for example, retain information that is not relevant to their clinical care of the patient. |
|
Not to be destroyed |
|
|
GP medical records, relating to HM Armed Forces. This refers to GP records of serving military personnel that were inexistence prior to them enlisting and held by HSCB |
These records should not be destroyed, however if the HSCB is notified of the death of such a patient the "not for destruction" marking should be removed and the records retained in the same way as for any other deceased patient |
|
Following the death of the patient, the recrods should be retained for 10 years after their death |
|
G51 |
GP electronic patient record including those serving a period of imprisonment and out of hours services |
GPs must not destroy or delete their electronic patient records for the foreseeable future, unless and until such times as these records are transfeerable in their entirety (including the audit trail) between clinical systems and from a GP system to the HSCB/BSO |
Good practice guidelines for general practice electronic patient records (version 4) |
Not to be destroyed |
|
G52 |
GP medical records of those serving a prison sentence of more than 2 years, in existence prior to their imprisonment |
GP Medical Records relating to those serving a prison sentence of more than two years should be sent to the HSCB. The HSCB should mark the records “not for destruction”. If the HSCB is notified of the death of such a patient the “not for destruction” marking should be removed and the records retained in the same way as for any other deceased patient. |
|
Not to be destroyed. This refers to GP records of serving prisoners that were in existence prior to their imprisonment. After their death, the records should be retained for 10 years. |
|
G53 |
Health visitor records (for children these become school nursing records) See AD-025 |
Retain until the patient’s 25th birthday or 26th if young person was 17 at conclusion of treatment, or eight years after death. 10 years for all other cases |
|
Destroy |