IGSOP07 Record Retention & Disposal SOP by Provide Community

Record Retention & Disposal

Standard Operating Procedure

Version: V2

Ratified by: Quality Reference Group

Date ratified: 15/12/2023

Job Title of author: Information Governance and IT Projects Manager

Reviewed by Committee or Expert Group

1. Introduction

A systematic and planned approach to the management of records within an organisation, from the moment they are created to their ultimate disposal, ensures that the organisation can control both the quality and the quantity of the information that it generates; it can maintain that information in a manner that effectively serves the needs of organisation and of the citizen; and it can dispose of the information when it is no longer required.

All records must be managed through the stages of the records management lifecycle including retention and destruction. Do not be tempted to destroy records once you think they have become obsolete.

2. Scope

This procedure relates to all Provide Group records including administrative (corporate) and health records. This procedure applies to records in any format. This includes, but is not limited to:

• Electronic records, including emails

• Paper / manual records

• Microfilms / Microfiche

• Films, photographs, slides, and other images including digital; and

• Memory Cards, USB sticks, and other removable media

• Legacy Audio and video tapes, cassettes, CD-ROM, etc

The objectives of the procedure are:

• To ensure that there are appropriate secure controls in place for the archiving and destruction of records

• To ensure that archiving and relevant destruction is managed.

3. Procedure

Once records have ceased to be active Provide has a duty to retain them for specific time periods. The Department of Health has published guidance on minimum retention periods for all records (health and non-health) which depends upon their importance and if they are likely to be needed again even after the death of a patient. These are listed on the Provide Intranet.

When records are no longer required for the conduct of current business, their placement in a designated secondary storage area is an effective way to store them allowing active records storage areas to operate more effectively, free from the clutter of non-active records.

After a record has been kept for its specific retention time it will be appraised by the local service manager. A decision will be made whether to keep the record permanently where it will be sent to an approved archive site or destroyed under confidential conditions by an approved document destruction service. All records to be archived must be prepared in line with the local procedure ‘Procedure for Preparing Records for Archive’. A request form must then be submitted to the Information Governance department. A record of all decisions must be retained, and the date of destruction will be recorded for each record destroyed.

The disposal of records is defined as the point in their lifecycle when they have reached the end of their retention period and are either transferred to a permanent archive or destroyed. The process of disposition has many steps; in particular it is essential that all records are catalogued prior to destruction so that the organisation can evidence the actions that it has taken with regard to its records.

All non-active clinical records than can be forwarded to the archive record library managed by Pinnacle Data Management (PDM) where they will be stored and available for access. Records stored in this way will be available to be picked up on request or securely delivered.

All active clinical records that are either supporting current care or are likely to be required to be accessed on a regular basis should be kept locally. If storage is a problem arrangement may be made to hold the records at the archive store. Please discuss your requirements with the IG team.

Electronic Record Formats

The principles for the management and retention of electronic records are the same as for manual records. For example, emails produced or received in the conduct of Provide business are considered to be corporate records.

All electronic records have to be archived and catalogued prior to their destruction.

The Information Technology department has guidelines around electronic storage routines, especially concerning use of e-mail, and these should be followed.

Retention Periods

If you are responsible for records management within your service, take time to familiarise yourself with the records retention schedules.

The most commonly used retention periods for Health Records within the organisation are:

Type of document or record: Retention period:

Children and Young People

Diaries – health visitors, district nurses and Allied Health Professionals

Until 25th Birthday or 26th Birthday if young person was 17 at conclusion of treatment, or 8 years after death.

2 Years after end of year which diary relates. Patient specific information should be transferred to the patient record.

Refrigerator Temperature

1 year. (Refrigerator records to be retained for the life of any product stored therein, particularly vaccines)

Risk Assessment Records Retain the latest risk assessment until a new one replaces it.

Records of destruction of individual health records (case notes) Permanently

Sexual Health Records

Smoking Cessation Records

Ward registers, including daily bed returns (where they exist in paper format)

10 years (in adults) or until 25th birthday in a child (age 26 if entry made when young person was 17), or 8 years after death.

2 Years unless there are clinical indications to keep them longer.

2 Years after the year to which they relate

Adult social care records (including care plans 8 years

Please refer to the Records Retention Schedules of the NHS Digital Records Management Code of Practice for Health and Social Care 20211. This can be accessed here.

Appraisal

When a record comes up for destruction it will be reviewed as follows:

• Value for research purposes

• Value for legal purposes

• Value for historical purposes i.e. sampling for permanent retention at the Public Records Office; and

• Identified familial illnesses

Ideally the above evaluation should take place prior to the record coming to the records archive store. However, in recognition that information changes, checks will be made prior to final destruction taking place.

A list will be issued to the Information Governance Team to confirm that destruction can proceed, after being reviewed by the local service manager. If any of the above criteria for retention are identified this will be highlighted. In all cases confirmation will be sought that destruction can take place.

1 NHS Digital Records Management Code of Practice for Health and Social Care (2021) Records Retention Schedules updated 19 October 2023. Link: Records Management Code of Practice - NHS Transformation Directorate (england.nhs.uk), (accessed online November 2023).

A check will be made by the service that the notes do not include any documentation with a later date or information, and which would render the record liable for further retention.

The destruction criteria will be reviewed annually to identify if any special clinical/corporate reasons exist which may mean retention of a class or type of record becomes necessary i.e. for research purposes.

Where no special reasons for retention are identified, the records will be destroyed in a secure manner and certification of this process will be retained by Provide. The organisation utilises on site secure shredding contractors who provide a Certificate of Destruction.

All clinicians and managers will have responsibility for marking files upon discharge/closure if they may be considered necessary for retention as a special category. The case note folder has a retention, disposal and destruction panel printed on the rear inside back cover for this purpose. Corporate folders should be marked appropriately.

Destruction of Records

The destruction of records is an irreversible act. All destruction of records will be managed by the Information Governance Team

The methods employed for destruction of confidential health records will be appropriate to ensure that their confidentiality is fully maintained throughout the process(es). Under normal conditions destruction will be by confidential shredding or permanent erasure in the case of Electronic records Destruction should not be undertaken without the authorisation of the Information Governance and IT Projects Manager or representative.

Tracing and Tracking

You must record the movement of records from your area to the archive records store. The final movement of records into the archive store for retention or destruction will be recorded by records service staff as part of the disposition process.

Access to Records

While records are stored in the records archive store, they will still be available for access under the Data Protection Act (2018) /General Data Protection Regulation (2016) or Freedom of Information Act (2000). Requests for access must follow the prescribed procedures which are laid down in statute. The Access to records process is managed by the Information Governance team.