Disposal Schedule - Section G part 1

Work area - Health Acute and Community

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
Retention Period

Revelant Legislation/
Derivation

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)
(Where a patient is transferred to the care of another HSC organisation all relevant clinical information must be transferred to the patients' health record held at that organisation)

 

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.
Where the information is NOT transferred into a health record, the tapes should be retained for 10 years

The Limitation (Northern Ireland) Order 1989

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

General Medical Council guidance

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
Where a health visitor visits a child the record of the visit should become part of the patient's record and retained until their 25th birthday or 26th birthday if an entry was made when the patient was 17 or 10 years after the patient's death if patient died while in the care of the organisation. This also applies to any other information that relates to patient care recorded by the health visitor for these purposes. Other information should be retained for a period of two years from the end of the year to which it relates

 

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.
If the illness of death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the advice of clinicians should be sought as whether to retain records for longer period

 

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
See D3

 

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
(see GMGR Section G103-G106 for X-rays)

 

 

 

 

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
from prison

 

Destroy

G32

General dental services patient records

six years

General Dental Services Regulations (Northern Ireland) 1993 as amended by the General Dental Service (Amendment) Regulations (Northern Ireland) 2008

Destroy

G33

Orthodontic records

six years

General Dental Services Regulations (Northern Ireland) 1993 as amended by the General Dental Service (Amendment) Regulations (Northern Ireland) 2008

Destroy

G34

Dental and epidemiological surveys

Review after 30 years

 

Determined
on review

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

Para 1.2.71 National Institute for Health and Clinical Excellence Donor breast milk banks the operation of donor milk bank services February 2010

Destroy

 

Donor milk used

30 years

Para 1.2.74 National Institute for Health Clinical Excellence Donor breast milk banks the operation of donor milk bank services February 2010

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

See also Guidance on the Retention and Disposal of Hospital Notes, British Association for Sexual health and HIV (BASHH)

Destroy

G49

GP Medical Records

GP Medical Records should be returned to the HSCB when:

  • a patient dies

  • the person is no longer a patient of the GP

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.
In the case of a child if the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, the advice of clinicians should be sought as to whether to retain the records for a longer period.

The Health & Personal Social Services (General Medical Services Contracts) Regulations (NI) 2004, S.R. 2004 No. 140

Destroy

 

GP medical records - maternity records

25 years after last live birth

The Health & Personal Social Services (General Medical Services Contracts) Regulations (NI) 2004, S.R. 2004 No. 140

Congenital Disabilities (Civil Liability) Act 1976, Consumer Protection (Northern Ireland) Order 1987

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

The Health & Personal Social Services (General Medical Services Contracts) Regulations (NI) 2004, S.R. 2004 No. 140

Royal College of Psychiatrists

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

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