Disposal Schedule - Section G part 2

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, nursing, 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 Relevant Legislation/Derivation Final Action
G54 Hospital acquired infection records  six years   Destroy
G55 Human fertilisation records, including embryology records

Treatment Centres
The following retention periods apply to data held by clinics as established by HFEA General Directions 0012 version

  • Where it is known that a birth has resulted from treatment – 30 years after the child’s birth.
  • Where it is known that no birth has resulted from treatment – 30 years after conclusion of treatment.
  • Where the outcome of treatment is unknown – 50 years after the information was first recorded.

HFEA Data Protection Policy Version 2 February 2009

Directions given under the Human Fertilisation and Embryology Act 1990, 24 January 1992 (this Act is subject to review by the Government:

http://www.hfea.gov.uk/docs/
2009-09-07_General_directions_
0012_-_Record_retention.pdf
 

Determined on review after consultation with Trust medical and records management staff
  Human fertilisation records, including embryology records

Storage centres

Where gametes, etc have been used in research, records must be kept for at least, 50 years after the information was first recorded

This applies to centres in respect of information which they are directed to record and maintain under a treatment/storage licence. Determined on review after consultation with Trust medical and records management staff
  Human fertilisation records, including embryology records

Research centre

(a) the total number of embryos or human admixed embryos created, used or disposed of during the research project;

(b) the results of the research project; and

(c) the conclusions drawn from the research project.
 

Such Records are to be kept for three years from the date of final report of results/conclusions to Human Fertilisation and Embryology Authority (HFEA).

Where a research project involves the derivation of stem cells for human application, a record of the information specified must be retained for a period of at least 30 years from the date the final report of any research project is submitted to the Authority.

Determined on review after consultation with Trust medical and records management staff
G56 Human tissue (within the meaning of the Human Tissue Act 2004) (see Forensic medicine above) 

For post mortem records which form part of the Coroner’s report, approval should be sought from the Coroner for a copy of the report to be incorporated in the patient’s notes, which should then be kept in line with the specialty, and then reviewed. 

All other records retain for 30 years. 

Human tissue (within the meaning of the Human Tissue Act 2004) Destroy
G57

Immunisation and vaccination records – This information is held in Health Visitor and GP records for preschool children and also on the Child Health System.

When a child goes to school and receives immunisations at school these are only recorded on the Child Health System, and not in GP records.  GPs may also record information about immunisations for travel for people of all ages, in their own records which is not recorded on the Child Health System.

For children and young people – retain until the patient’s 25th birthday or 26th if the young person was 17 at conclusion of treatment.

All others retain for 10 years after conclusion of treatment. 

  Destroy
G58 Intensive Care Unit charts  Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.   Destroy
G59 Joint replacement records 

10 years

For joint replacement surgery the revision of a primary replacement may be required after 10 years and there is a need to identify which prosthesis was used originally. There is only a need to retain the minimum of notes with specific information about the original prosthesis for the full 10 years. 

http://www.njrcentre.org.uk

Consumer Protection (NI) Order
1987 and Article 8(3) The
Limitation (Northern Ireland)
Order 1989 [Link to an external website]
 

Destroy
G60

Learning difficulties – (records of patients with)

Specific Learning Difficulty is where a person finds one particular thing difficult but manages well in everything else.

Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68. Royal College of Psychiatrists
 

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G61

Learning Disabilities

NB A general learning disability is not a mental illness – it is a life-long condition, which can vary in degree from mild to profound.

Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.
 
Royal College of Psychiatrists
 

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G62

Medical Records of those serving a period of imprisonment

24 HR Nursing Handover Report

Records wherever they are held other than the records listed below retain for 10 years after the 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.

Maternity records – 25 years after last live birth

Where the prisoner was suffering from a mental health disorder within the meaning of the Mental Health (NI) Order 1986, 20 years after the date of the last contact; or 10 years after patient’s death if sooner.
See AM 007

  Destroy
G63

Hospice Care

(For Example Macmillan Marie Curie, NI Hospice, The Palliative and End of Life Care patient records– community and acute) 

Organisations regulated under The Independent Health Care Regulations (Northern Ireland) 2005 see GMGR Section O16

Otherwise retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19.

 

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G64 Maternity (all obstetric and midwifery records including those of episodes of maternity care that end in still birth or where the child later dies). Where the baby receives donor milk the baby’s record should be kept for 30 years.

25 years after last entry or update.

See AD-012

See AD-027
 

See Addendum 1

Joint Position on the Retention of Maternity Records devised by: British Paediatric Association
Royal College of Midwives
Royal College of Obstetricians and Gynaecologists
United Kingdom Central Council for Nursing, Midwifery and Health Visiting

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

Determined on review after consultation with Trust medical and record management staff.
G65 Mental Health Records – Child & Adolescent (includes clinical psychology records) not listed elsewhere in this schedule. 20 years from the date of last contact, or until their 25th/26th birthday, whichever is the longer period. Retention period for records of deceased persons is eight years after death.   Destroy
G66 Mammography screening      
  Mammograms & Reports

Normal packet – nine years after date of final attendance

Screen detected cancers – Indefinitely

Interval cancers – Indefinitely

Interesting cases – Indefinitely

Retention periods should be calculated from the end of the calendar year following the conclusion of treatment or the last entry in the record.
 

BFCR (06)4 Royal College of Radiologists Destroy
  Research cases

15 years after date of final attendance

Retention periods should be calculated from the end of the calendar year following the conclusion of treatment or the last entry in the record.

BFCR (06)4 Royal College of Radiologists Destroy
  Age Trial Cases

nine years after date of final attendance

Retention periods should be calculated from the end of the calendar year following the conclusion of treatment or the last entry in the record.

BFCR (06)4 Royal College of Radiologists Destroy
  Deaths

nine years after final attendance

Retention periods should be calculated from the end of the calendar year following the conclusion of treatment or the last entry in the record.

BFCR (06)4 Royal College of Radiologists

Destroy
G67 Medical illustrations  See photographs GMGR Section G90 Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.  

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G68 Mentally disordered persons (within the meaning of the Mental Health (Northern Ireland) Order 1986)

20 years after no further treatment considered necessary; or eight years after the patients death if the patient died while still receiving treatment

With regard to the selection of records for medical research purposes, PRONI advises that medical staff should recommend records for permanent preservation.  Decisions should be based on the medical research potential of the records, e.g. on the different forms of mental disorder (genetic or otherwise) and on the different treatments

See AD-018

When the records come to the end of their retention period, they must be reviewed and not automatically destroyed. Such a review should take into account any genetic implications of the patient’s illness. If it is decided to retain the records, they should be subject to regular review.

 

Transfer to PRONI all files for each Census Year See AD-006 (see Glossary) beginning with 1951 and in addition all files related to:

See AD-004
a) suicide cases or where the cause of death was uncertain;

b) cases which have already been the subject of medical research by doctors or record drug trials;

c) cases of medical research potential;

d) social worker’s reports and related records (e.g. personal “life testimonies” by patients – retained because of their social historical content);

e) criminal mentally disordered offender cases where the person is convicted of a serious crime e.g. homicide; and

f) mentally disordered offender cases where the person has been transferred to the following high secure or medium secure units:

Ashworth Hospital;

Broadmoor Hospital;

Carstairs Hospital;

Rampton Hospital;

Shannon Clinic,

Knockbracken.

G69 Microfilm/ microfiche records relating to patient care  Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68. See GMGR Part 1 Guide to preservation Microfilming 2000

Determined on review

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G70 Midwifery records 

see (Maternity) GMGR Section G64

25 years after the entry or update

Midwives rules and standards 05.04 (rule 9) Destroy
G71 Mortuary registers (where they exist in paper format)  30 years

The Royal College of Pathologists.

The Royal College of Pathologists - The retention and storage of Pathological records & specimens (4th Edition, 2009)

Destroy
G72 Music therapy records  Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.  

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G73 Neonatal screening records 25 years   Destroy
G74 Nicotine Replacement Therapy (dispensed as smoking cessation aid) two years unless there are clinical indications to keep them for longer   Destroy 
G75 Notifiable diseases book six years   Destroy
G76 Occupational therapy records  Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.  

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G77 Occupationally Related Diseases for example, asbestosis, pneumoconiosis, byssinosis) 10 years after date of last entry in the record British Thoracic Society’s Occupational and Environmental Lung Disease Specialist Advisory Group Destroy
G78

See AM-001

Oncology (All records)

     
  Paediatric Oncology Records where condition was diagnosed prior to the 18th birthday Until 65th birthday BFCO (06)2 issued by the Royal College of Radiologists with the support of the Joint Council for Clinical Oncology Determined on review after consultation with Trust medical and Records Management Staff 
  All other oncology records 50 years or eight years after death. BFCO (06)2 issued by the Royal College of Radiologists with the support of the Joint Council for Clinical Oncology Determined on review after consultation with Trust medical and Records Management Staff 
G79 Operating Theatre Lists  four years    Destroy
G80 Operating theatre registers eight years after the year to which they relate   Destroy
G81 Ophthalmic Screening and General Ophthalmic Services (GOS) A contractor shall keep a proper record in respect of each patient to whom he provides general ophthalmic services, giving appropriate details of sight testing, for seven years from and including the date of the last recorded sight test “… but it is recommended for best practice, in line with the professional bodies, that GOS records are retained for 12 years”

Paragraph 7 Schedule 1
Health and Personal Services General Ophthalmic Services  Regulations (NI) 2007 –S.R.2007 No.436

Legislation

 

Destroy
G82 Orthoptic records Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.

British and Irish Orthoptic society

http://www.orthoptics.org.uk/
orthoptists/Orthoptic_
competency_standards.pdf

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G83 Out-patient lists two years after the date to which they  relate   Destroy
G84 Paediatric records  see Children and young people GMGR Section G19   Determined on review after consultation with Trust professional and records management staff
G85

Parent-held Records

(that is, records for sick/ ill children being cared for at home by community teams NOT the records of newborn children.

These records are HSC records that belong to clinical staff but which are held by the parent.

At the end of an episode of care the HSC organisation responsible for delivering that care and compiling the record of the care must make appropriate arrangements to retrieve parent-held records. The records should then be retained until the patient’s 25th birthday, or 26th birthday if the young person was 17 at the conclusion of treatment, or eight years after death.    Destroy
G86

See AD008

Patient/Client Clinical/Medical Case Records (not covered in other categories)

See AD-033

See AD-034

eight years after conclusion of treatment   Determined on review after consultation with Trust medical and record management staff.
G87 Patient Group Directions (PGDs) master copies, lists of authorised Practitioners, and records of version numbers  25 years   Destroy
G88 Patient-held records At the end of an episode of care the HSC organisation responsible for delivering that care and compiling the record of the care must make appropriate arrangements to retrieve patient-held records. The records should then be retained for the period appropriate to the specialty.   Destroy
G89 Patients involved in clinical trials 15 years after conclusion of treatment.   Determined on review after consultation with Trust medical and records management staff
G90

Photographs – (where the photograph refers to a particular patient it should be treated as part of the case health record)

In the context of GMGR a “photograph” is a print taken with a camera and retained in the patient record. 

Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.

Unless there is a clinical or legal reason for retaining the digital image and a print is placed on the patient’s record, there is no requirement to retain the digital image. 

 

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G91 Physiotherapy records Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.  

Destroy.

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G92 Podiatry Records Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68.  

Destroy

See GMGR Section G19 for children’s records and GMGR Section G68 for mentally disordered persons’ records

G93 Pre 1948 Records  Records in this category may already have been destroyed or sent to PRONI for permanent preservation.  Any records which still exist and do not fall within any other category should be referred for a special PRONI Review.   Special Review by PRONI
G94 Private patients records admitted to hospital under Article 31 of the Health and Social Services (Northern Ireland) Order 1972 Although technically exempt from the Public Records Act (Northern Ireland) 1923, it is appropriate to treat as if they were not exempt in which case retention periods relevant to the condition apply.   Destroy
G95 Radiation dose records for classified persons 50 years from the date of the last entry or age 75, whichever is the longer Ionising Radiation Regulations
( NI ) 2000, SR 2000 No 375.
(reg. 19(3)(a))
Destroy
G96

Record of patients property handed in for safe keeping

Patients’ property

six years after the end of the financial year    Destroy
G97 Transplant records – Patient who has received an organ transplant 11 years beginning on the date of the patient’s death or discharge whichever is the earlier.  Precedent Cases should be transferred to PRONI.   Determined on review after consultation with Trust Medical and Records Management staff.
G98 Ultrasound records(e.g. vascular, obstetric) Retain for the period of time appropriate to the patient/specialty, for example, children’s records see GMGR Section G19, for mentally disordered persons see GMGR Section G68, or 8 years after the patient's death if patient died while in the care of the Organisation.   Destroy
G99

See AD028

Video records/voice recordings relating to patient care/video records/ video-conferencing records related to patient care/DVD records related to patient care

Includes:

Telemedicine records Out of hours records (GP cover)

NHS Direct records

eight years subject to the following exceptions or where there is a specific statutory obligation to retain records for longer periods:

Children and young people:
Records must be kept until the patient’s 25th birthday, or if the patient was 17 at the conclusion of treatment, until their 26th birthday, or until 8 years after the patient’s death if sooner.

Maternity:
25 years

Mentally disordered persons:
Records should be kept for 20 years after the date of last contact between patient/client/ service user and any healthcare professional or eight years after the patient’s death if sooner.

Cancer patients:
Records should be kept until eight years after the conclusion of treatment, especially if surgery was involved. The Royal College of Radiologists has recommended that such records be kept permanently where chemotherapy and/or radiotherapy was given.
 

  Destroy
G100

Waiting List Information

Letters and responses to and from clients/ patients/Service user asking if they wish to remain on a waiting list.

See AD-017

Keep in the patient records according to speciality.   Destroy
G101 Waiting List See Reference GMGR Section Q1 for returns sent to the Department.  The actual list should be kept on a three year rolling cycle.   Destroy
G102 Ward Registers including daily bed returns one year   Destroy
G103 X-ray films (including other image formats for all imagining modalities/ diagnostics)

General Patient Records – eight years after conclusion of treatment.

Children & Young People – Until the patient’s 25th birthday, or if the patient was 17 at conclusion of treatment, until their 26th birthday or eight years after the patient’s death if sooner.

Maternity – 25 years after the birth of the child, including, still births.

Clinical Trials – 15 years after completion of treatment.

Litigation – Records should be reviewed 10 years after the file is closed.  Once litigation has been notified (or a formal complaint received) images should be stored until 10 years after the files has been closed.

Mental Health – 20 years after no further treatment considered necessary or eight years after death.

Oncology – see GMGR Section G78 Oncology Records.

BFCR(06)4 – Royal College of Radiologists Guidance from the Royal College of Radiologists regards “images and request information (to be) of a transitory nature” (para 2.1), but goes on to say: “It is now considered that best practice should move towards retention of image data for the same duration as report and request data”  (para 2.2) and recommends that “the retention period for text and image data are equal and comply with the published retention schedules” (para 7.1):

http://www.rcr.ac.uk/ publications.aspx?PageID=310& PublicationID=234

The Ionising Radiation (Medical Exposure) Regulations 2000
 

Destroy
G104 X-Ray Referral/Request Cards eight years providing there is a record in the patient’s health record that a referral /request was made for an x-ray.

Guidance from the Royal College of Radiologists regards “images and request information (to be ) of a transitory nature” (Para 2.1) but goes on to say: ”It is now considered that best practice should move towards retention of image data for the same duration as report and request data” (Para2.2) and recommends that “the retention period for text and image data are equal and comply with the published retention schedules”(para7.1):

http://www.rcr.ac.uk/ index.asp?PageID=310& PublicationID=234 

The Ionising Radiation (Medical Exposure) Regulations 2000

Destroy
G105 X-ray registers eight years The Ionising Radiation (Medical Exposure) Regulations 2000 Destroy
G106 X-ray reports (including reports for all imaging modalities) To be considered as a permanent part of the patient record. The Ionising Radiation (Medical Exposure) Regulations 2000 As per the final action for the patient record
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