APPENDIX
A
EXPLANATION OF RECOMMENDED MINIMUM RETENTION PERIODS
1. For
the purposes of this guidance records contained on "non-paper"
media (eg microfilm, computer files, slides and specimens) should be
treated in the same way as paper records with the same minimum retention
periods applying to them (but see paragraph 19).
2. At
the conclusion of periods set out in this guidance the records may be
destroyed but there is no obligation to do so. Destruction of health
records should be based on appropriate health professional advice.
3. Health
Boards, Trusts and GPs, as producers of products and equipment, are
affected by the provisions of the Consumer Protection Act 1987 covering
the liability of producers for defective products. They may also be
liable in certain circumstances as suppliers and users of products.
An obligation for liability lasts for 10 years and within this period
the Prescription and Limitation (Scotland) Act 1973, as amended by the
Consumer Protection Act 1987, provides that the pursuer must commence
any action within 3 years' from the date on which the pursuer was aware
of the defect and aware that the damage was caused by the defect. This
means that if a defective product was likely to have affected the health
of a patient, then the patient's record would have to be retained for
at least 13 years'. It will be for Boards, Trusts and GPs to make their
own judgement in such cases on whether any health records should be
retained for this minimum period in order to defend any action brought
under the Consumer Protection Act 1987.
4. It
will be for Health Boards, Consultants, GPs, Dentists,
Pharmacists, Opticians, Occupational Health Services, Cancer Registries,Nurses,
Midwives, Health Visitors, Community Nurses, and as appropriate NHS
Trusts, to decide which of their records should be retained for clinical
or research purposes.
General
Hospital and Community Health Service Health Records
5. There
will be no change in the present minimum retention period of 6 years
following the date of the last recorded entry or 3 years after death.
All records must be kept in the original form for at least the first
3 years of the period but may be microfilmed or transferred to other
media thereafter and held in that form for the remainder of the period.
Children's
and Young Adults Health Records
6. Under
the terms of sections 17 and 18 of the Prescription and Limitation (Scotland)
Act 1973 it is normally the case that any action for damages in respect
of personal injuries should be raised within 3 years from the date on
which the injuries were sustained or, in the case of medical treatment,
of the treatment to which the injuries relate. This period may be extended
however if the pursuer, in the opinion of the court, could not have
been in the position to know that the injury was sufficiently serious
to justify the bringing of an action, that the injury was attributable
in whole or in part to an act or omission on the defenders part or that
the defender was a person to whom the injuries were
attributable in whole or in part. In other words the period of 3 years
may in fact start after the date of termination of the treatment. There
is also to be left out of account any period during which the person
who sustained the injuries was under legal disability either through
non-age (ie under the age of 16) or unsoundness of mind (see paragraph
12) which does not mean insanity but an inability of the injured person
by reason of their mental state, to manage their own affairs in relation
to the relevant event and injury.
7. In
the circumstances, to allow a sufficient period for any legal action
to be initiated the general minimum retention period for children and
young adults has been changed to require records to be retained until
the individual reaches the age of 25 years or 3 years after death if
this is earlier.
Obstetric
Records
8. Associated
with the records of children and young adults is the need to retain
a mother's obstetric records. These should be retained for 25 years
after the birth of the child (including stillbirth).
Psychiatric
Records
9. The
retention periods for psychiatric records will change and
differentiate between those containing entries made on or before
31 December 1960 and those containing only entries made after that date.
This date has been chosen on the grounds that new admission procedures
under the Mental Health (Scotland) Act 1960 came into operation on 1
January 1961.
10. There
will be no change in the retention of psychiatric records containing
entries made on or before 31 December 1960 and these should continue
to be retained indefinitely. However psychiatric records with the first
entry made on or after 1 January 1961 should be retained for the lifetime
of the patient and 3 years after death.
11. These
proposals do not prevent retention for longer periods and because of
the unique time series of psychiatric records held in Scotland there
may be grounds for retaining certain records in perpetuity.
Health
Records of Persons of Unsound Mind
12. Under
the Prescription and Limitation (Scotland) Act 1973 a person who has
been declared of unsound mind may sue for damages up to 3 years after
being declared sound of mind. As explained earlier in this guidance,
unsoundness of mind does not mean insanity but an inability of the injured
person by reason of their mental state to manage their own affairs in
relation to the relevant event and injury. The provisions of the Act
will not necessarily apply to all psychiatric records but where an action
is initiated it will affect not only the psychiatric records but all
the health records of that patient. For example, a patient on being
declared sound of mind has 3 years in which to sue for damages in relation
to a hip operation performed while he was unsound of mind even if that
operation had been performed 20 years earlier. It will be for Health
Boards and NHS Trusts to make their own judgement in such cases in the
light of local circumstances.
GP
Records held by Health Boards
13. There
will be no change in the retention period for GP records held by Health
Boards where the patient has died. This will remain at 3 years after
death. Where individuals leave the country temporarily and have expressed
an intention to return, the records should be retained for 6 years or
such reasonable longer period as may be agreed with the GP or Board
and the person concerned. However, as explained in paragraph 7, records
of children and young adults should be retained until the individual
reaches the age of 25 or 3 years after death if this is earlier.
14. The
Health Board should consult with the GP Sub-Committee of the Area Medical
Committee regarding the arrangements for the disposal of such records
(eg to agree any particular category of record which needs to be held
for a longer period).
Records
of Cancer Patients
15. There
is a need to maintain on a long-term basis records which are kept on
patients undergoing radiation therapy and chemotherapy. These records
are required not only during the lifetime of the patient but also after
death in order to allow an adequate and detailed audit of treatment
to be undertaken. Accordingly, all records, including written records
and radiographs of patients treated for cancer should be retained for
the lifetime of the patient and 3 years after death. Even after this
period, destruction of all such records may only be carried out after
consultation with the consultant in charge.
Records
of Patients with Genetic Disorders
16. In
order that clinicians may provide accurate genetic advice it is essential
that a definite, confirmed diagnosis is made of the condition that is
suspected to be fami]ial. This often requires not only confirming the
diagnosis of the clinical condition in the affected individual but also
determining the mode of transmission of the disorder within the family.
Thus it requires confirmation of the diagnosis in any other members
of the family who are thought to have been affected in the same or in
previous generations and the medical records of family members are often
required for confirming the disorder.
17. Accordingly,
given the nature of this particular category of health record it would
not be appropriate for the Management Executive to recommend a specific
minimum retention period for such cases. In the circumstances it is
for provider Units (including NHS Trusts), on the advice of the consultants
in charge, to consider the retention of records (or parts of them),
in respect of patients and their families with disorders which may be
genetic, beyond the minimum period of 6 years as required for health
records generally.
X-Ray
Films
18. The
bulk of x-ray film gives rise to special storage problems. In 1990,
the Royal College of Radiologists issued a resume of the issues relating
to the retention of x-ray film. In this, it was pointed out that almost
all records were in file within 3 years of being produced and it was
recommended that the radiologists report rather than the x-ray film
should be considered the primary record for retention. They therefore
suggested that "the film envelope, and its content, save in special
interest groups, may be discarded once 3 years has elapsed since the
most recent previous examination." Special interest groups were
identified as "paediatrics, maternity, research, teaching hospitals"
and "radiotherapy". Ideally x-ray film should be retained
for the same period as other health records in accordance with the recommendations
in this guidance. However it is recognised that other considerations
may make this impractical and unreasonable. It is therefore recommended
that provider units, in consultation with their purchasers and relevant
clinicians, and with reference to current professional guidance, should
determine the duration for which x-ray film should be retained, taking
into account clinical need, special interest groups, cost of storage
and the availability of storage space. X-ray reports are an integral
part of the main health record and are therefore covered by the appropriate
minimum retention periods recommended in this guidance.
19. Pathological
Specimens
19.1 Cervical Smears:
The current professional guidance contained in the "Strong Report"
on the Cervical Cytology Service in Scotland recommends that smears
and records should be stored for 10 years in normal cases and indefinitely
for abnormal cases. This guidance will continue to apply.
19.2 Histological
Specimens: These are blocks of tissue removed at operation or biopsy
for which slides are then made for microscopic examination and diagnosis.
The current practice is that blocks are retained indefinitely, and
slides made from these specimens are kept for a minimum of 10 to 15
years', depending on the storage space available. This practice should
be maintained.
Retention of Records
for Clinical Trials
20. The
EC Directive on Good Clinical Practice for Investigators taking part
in clinical trials, which was implemented in July 1991, recommends that
patient files and other source data must be kept for the maximum period
of time permitted by the hospital, institution or private practice,
but not less than 15 years. The Directive rightly places the responsibility
for retention of records for clinical trials on the investigator.
21. It
is important that investigators should not assume that Health Boards
or Trusts are required to retain the records beyond the minimum retention
periods stated in this guidance and they must make sure suitable arrangements
for retention and storage have been made with provider management before
the trial starts. While all NHS Hospitals, Trusts and Practices should
be encouraged to support ethical research, the
Directive will place additional work on the institution which is likely
to go far beyond routine requirements. In the circumstances investigators
and sponsors of clinical trials must recognise that agreement can not
be assumed and that special arrangements will be needed for each project.
This may involve payment for the additional record handing and storage.
Historical
Records
22. No
surviving health record dated 1948 or earlier should be destroyed. After
expiry of the minimum retention periods, post 1948 health records may
be destroyed but there is no obligation to do so. It will be for Health
Boards, NHS Trusts or GPs to decide which of their post 1948 health
records should be retained for clinical or research purposes. Confidentiality
of health records should be maintained for 75 years (100 years for minors)
following the last recorded entry unless special permission is obtained
from the relevant medical officer.
23. There
is an obligation to preserve appropriate records for historical use
by a wide range of readers in the future. The most appropriate method
of retaining a selection for permanent preservation is by way of sampling.
Specialist advice is available in the first instance from the Archivist
of Greater Glasgow Health Board where a specialist sampling study has
been undertaken. Every Board or Trust should have access to the services
of a professional archivist. A number of Health Boards employ qualified
Archivists to look after their non-current health records and make them
available both to staff of the employing authority and members of the
public in consultation with the Keeper of the Records of Scotland. Advice
on the selection of health records -for preservation or destruction
is available from:
- The
Archivist, Dumfries and Galloway Health Board, Crichton Royal Hospital,
Dumfries, DG1 4TG (Tel: 0387 55301 Ext 2360)
- The
Archivist, Grampian Health Board, Aberdeen Royal Infirmary Woolmanhill,
Aberdeen AB9 lEF (Tel: 0224 663466)
- The
Archivist, Greater Glasgow Health Board, Glasgow University Archives,
Glasgow G12 8QQ (Tel: 041-330 5516)
- The
Archivist, Lothian Health Board, Medical Archive Centre, Edinburgh University
Library, Edinburgh EH8 9LJ
(Tel: 031-650 3392)
24. In
the case of areas which have no Health Board Archivist, the
Keeper of the Records of Scotland, Scottish Record Office, Edinburgh
EHl 3YY (Tel: 031-556 6585 Ext 131/132) will put enquirers in touch
with the nearest Health Board Archivist, or an appropriate local Archive
Office. Alternatively the Keeper's staff will offer advice on request.
SUMMARY OF MINIMUM
RETENTION PERIODS FOR PERSONAL HEALTH
RECORDS (At the conclusion of periods set out in this guidance the
records may be destroyed but there is no obligation to do so.)
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1. General
Hospital and
Community Health Service Health
Records
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a. Persons
aged 16 or over on date of admission
6 years following
the date of the last recorded entry or 3 years after
death.
b. Children's
and Young Adults'
Records (persons aged less than 16
on date of admission)
Until the person
reaches the age of 25 or 3 years after death if this is earlier.
c. Obstetric
Records (meaning the obstetric records of the mother)
25 years after
the birth of the child (including stillbirth)
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2.
Psychiatric Records
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Records containing
entries made on or before 31 December 1960 should be retained
indefinitely.
Records with
the first entry made on or after 1 January 1961 should be retained
for the lifetime of the patient and 3 years after death.
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| 3.
GP Records |
GP
records should normally be sent to the appropriate Health Board
on the death of a patient and retained for 3 years. Where individuals
leave the country temporarily and have expressed an interest to
return, the records should be retained for 6 years or such longer
period as may be agreed with the GP or Board and the person concerned.
However records of children and young adults should be retained
until the individual reaches the age of 25 or 3 years after death
if' this is earlier. Under certain circumstances GP records may
require to be retained for a longer period (see paragraph 14 of
Appendix A). |
| 4.
Records of Cancer Patients |
Records
of cancer patients should be retained for the lifetime of the patient
and 3 years after death. After this period, destruction of all such
records may only be carried out after consultation with the consultant
in charge. |
| 5.
Records of Patients with Genetic Disorders |
It
is for provider Units (including NHS Trusts), on the advice of the
consultants in charge, to consider the retention of records (or
parts of them), in respect of patients and their families with disorders
which may be genetic, beyond the minimum period of 6 years as required
for health records generally. |
| 6.
X-Ray Films |
Provider
Units, in consultation with their purchasers and with relevant clinicians,
should determine the duration for which x-ray film should be retained,
taking into account clinical need, special interest groups, cost
of storage and the availability of storage space. X-ray reports
are an integral part of the main health record and are therefore
covered by the appropriate minimum retention periods recommended
in this guidance. |
| 7.
Cervical Smears |
Smears
and records should be stored for 10 years in normal cases and indefinitely
for abnormal cases. |
| 8.
Histological Specimens |
Blocks
of tissue should be retained indefinitely and slides made from these
specimens should be kept for 10 to 15 years depending on the storage
space available.
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