Retention and Disposal of Records Policy and Procedure

________________________________________________________________

Retention and Disposal of Records Policy and

Procedure

Key Points

• This document applies to both Corporate and Medical Records

• The Medical Record Retention and Destruction Policy is at
Attachment 2

Ratified Date: February 2008

Ratified By: Information Governance Committee
Review Date: February 2011

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Meta Data

Document Title: Retention and Disposal of Records Policy and Procedure

Document Number:
Document Author: Bridget Francis
Accountable Director: Director of Governance and Standards
Source Directorate: Healthcare Governance
Date Ratified: February 2008
Date Of Release: February 2008

Review Date: February 2011

Related documents Freedom of Information Policy
Records Management: NHS Code of Practice
Medical Record Retention and Disposal Policy
(Attachment 2)
Confidentiality: Management, Security and Disclosure of
Confidential Information Policy and Procedure
HISS Case Note Tracking Policy
Record Keeping in Healthcare Policy
Risk Management Policy and Procedures
Relevant External Records Management: NHS Code of Practice
Standards/ NHSLA Standards
Legislation Information Governance Toolkit
Healthcare Standards
Data Protection Act
Access to Health Records Act 1990

Stored Centrally: Electronic copy on Intranet site

Revision History

Version Date of Document Author Ratified by Date

No. Release Ratified
V1.0 Feb 08 Information Governance Manager IGC Feb 08
V1.1 Feb 08 Information Governance Manager MRC April 08

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 Retention and Disposal of Records Policy and Procedure
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Table of Contents

Section Page
1 Introduction 4
2 Definitions 4
3 Scope 4
4 Purpose 5
5 The Trust’s Approach to Retention and Disposal of 5
Records
6 Retention and Disposal Procedures 5
6.1 Corporate Records 5
6.2 Storage of Records 6
6.3 Disposal of Records 6
6.4 Destruction of Records 6
7 Retention of Corporate Records Schedule 7
8 Retention of Medical Records Policy 7
9 Responsibilities 7
10 Training 8
11 Compliance 9
12 Launch Plan 9
13 Review 9

Attachment 1 Retention of Corporate Records Schedule

Attachment 2 Medical Record Retention and Disposal Policy

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1 Introduction

NHS organisations are under a duty (as indicated in the Public Records Act
1958) to keep all NHS records (i.e. patient, staff and business records) for a
minimum number of years.

The Department of Health publishes circulars which detail record retention

requirements, of these the most relevant one for Acute Trusts is the HSC
1999/053 “For the Record”, see:
http://www.dh.gov.uk/assetRoot/04/01/20/36/04012036.pdf

This Policy and Procedure applies to the Trust's statutory obligation in relation to
the retention and disposal of records. This Policy and Procedure does include
retention and disposal of medical/health records at Attachment 2. This Policy
and Procedure will provide a framework within, which the Trust will ensure
compliance with retention and disposal legislation and guidance. The Policy and
Procedure will underpin any operational procedures and activities connected with
the implementation of said legislation and guidance.

2 Definitions

2.1 Disposal:

"Disposal” in this context does not just mean Disposal: it embraces any
action taken [or yet to be taken] to determine the fate of records including
transfer to a permanent archive.

2.2 Review

Where it is not yet possible to determine the disposal mode and times of
records, they may be scheduled for “Review” at a later date. This type of
review involves bringing forward the records at a later date at which it is
hoped to determine their final disposal.

2.3 Retention

“Retention” usually means the length of time for which records are to be
kept. Thus it normally represents and will be expressed as a disposal
period.

3 Scope

This Policy and Procedure applies to:

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• all Trust staff including temporary, staff, volunteers and students
involved in the destruction/retention of information or records;
• electronic and manual health records;
• all records held locally in departments;
• all clinical and non-clinical records;
• X-rays;
• Scanned images.

4 Purpose

The Purpose of this Policy is to:

• ensure the Trust is compliant with The Freedom of Information Act 2000
and with particular relevance to the Code of Conduct on Records
Management issues under Section 46 of the said Act;

• provide the minimum periods of retention of corporate and clinical records

in a format that does not involve having to read lengthy circulars;

• lists how documents/files should be destroyed when no longer required

and how and when to store if records need to be retained for a longer
period of time than that specified within the relevant circular;

5 The Trust’s Approach to Retention and Disposal of Records

The Policy supports the principle that all records should be managed in a way
that allows the information contained within them to be available to the person
who needs them, at the time and place they are needed. The Policy provides the
Trust with the necessary guidance in relation to our legal obligation and practical
necessities for retaining and disposing of Trust records.

6 Retention and Disposal procedures for corporate and clinical records

This Procedure is concerned with corporate and clinical records, i.e., those that
concern the business of the organisation. It may however be incorporated into a
wider records management system covering all records within the organisation.

The records may be held electronically and/or manually and may contain
information from any of the categories below:

• Clinical records
• Administrative records including: HR, estates, financial and accounting
(e.g. budget information, annual report information);
• Information concerning complaint handling;
• Manual (e.g. telephone messages, working papers);
• Printouts of audit trails from computer/automated systems;
• Microfiche;
• Audio tapes, cassettes;
• Video tapes, CD-Rom;

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• Computer media e.g. CDs, floppy discs;
• Computer output e.g. paper, printout.

Regardless of type there is usually a requirement to keep a record for a minimum

number of years. This period of time is calculated from the end of the calendar or
accounting year following the last entry in the record (e.g. manual file, computer
record).

6.2 Storage of records

Hard copy records should be stored in a secure location when not being used
e.g. lockable filing cabinets, cupboards, rooms (locked and if appropriate alarmed
outside of normal working hours)

The accommodation should comply with health and safety requirements and
have proper environmental controls and adequate protection against fire, flood
and theft.

Electronic information should be stored on a suitable location on one of the Trust

Servers. Version control should be used in storing electronic information. Only
one copy of approved documentation should be stored. Standards in record
keeping will be developed to address these issues fully.

6.3 Disposal of Records

Disposal is wider than just destruction. it can also refer to the transfer of records
from one media to another e.g. paper records to CD Rom, or the transfer of
records from one organisation to another e.g. authorised archive office.

When using another organisation to archive records it is essential an

agreement/contract is in place detailing how the records will be archived and who
will be allowed access to them.

When an archived record is accessed a note must be made of:

• the date access occurred,

• the details of the person gaining access
• the reason access was required.

When a record is removed from the archive a note must be made of:

• the taker of the record,

• the taker’s signature or a receipt from them,
• the expected date of return,
• the date the record is returned.

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6.4 Destruction of Records

The destruction of records is an irreversible act. Many NHS records contain

sensitive and/or confidential information and their destruction must be undertaken
in secure locations and proof of secure destruction may be required. destruction
of all records, regardless of the media, should be conducted in a secure manner
to ensure there are safeguards against accidental loss or disclosure.

The normal destruction methods used within the NHS are:

• shredding,
• pulping
• incineration

7. Retention of Corporate Records Schedule

The Retention of Corporate Records Schedule (Attachment 1) outlines the

retention and disposal times for corporate records. This Schedule is based on
HSC1999/053. This is not an exhaustive list and changes and amendments may
need to be made according to Trust and Directorates needs.

8. Retention of Medical Records Policy

The Retention of Medical Records Policy, adapted from the Records

Management: NHS Code of Practice is at Attachment 2.

9. Responsibilities

9.1 Individuals

9.1.1 Chief Executive

The Chief Executive has delegated responsibility to the Director of Governance

and Standards for implementation and review of this Policy and Procedure.

9.1.2 Director of Governance & Standards

The Director of Governance and Standards is responsible for Information

Governance within the Trust. She/he will report to the Trust Board in relation to
Governance issues relating to retention and disposal and will liaise with the
Director of ICT/Medical Records as required.

9.1.3 Executive Directors

Executive Directors are responsible for ensuring that retention and disposal of
records is undertaken in line with this Policy and Procedure within their areas of
responsibility.

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9.1.4 Director of ICT

The Director of ICT is responsible for ensure that retention and disposal of
Medical Records is undertaken line with this Policy and Procedure.

9.1.5 Trust Information Governance Manager

The Information Governance Manager has day to day responsibility for the
management of information governance issues relating to retention and disposal.
The Trust Information Governance Manager will liaise with the Medical Records
Department appropriately and will provide reports to the Information Governance
Committee, Medical Records Committee and Governance & Risk Committee.

9.1.6 Individual Staff Responsibilities

All staff are responsible for ensuring that retention and disposal of records is in
line with this Policy and Procedure.

All managers, including managers of locally held records, must be identified as

responsible for each record type and for ensuring that there is an appropriate
system for registering the existence of the record through to final disposal.

The Trust recognises that some staff may have a disability such as visual
impairment. It is the responsibility of the directorate to make reasonable
adjustments such as providing this policy in large print or in Braille on request.

9.2 Board and Committee Responsibilities

9.2.1 Trust Board

The Trust Board is responsible for assuring that appropriate retention and
disposal systems are in place to enable the organisation to deliver its objectives.
It will delegate operational responsibility for retention and disposal to the
Governance and Risk Committee, Information Governance Committee and
Medical Records Committee.

9.2.3. Governance & Risk Committee

Retention and disposal is a component of the Trust’s overall Governance

agenda. The Governance & Risk Committee is responsible for ensuring that all
aspects of retention and disposal relating to corporate records are managed
throughout the organisation.

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9.2.4 Medical Records Committee

The Medical Records Committee manages and oversees implementation of the

retention and disposal of medical records.

10. Training

The Information Governance Department will ensure provision of training for

relevant managers, supervisors and staff to enable them to carry out their duties
and responsibilities relating to retention and disposal of corporate records.

The Medical Records Department will ensure provision of training for relevant
managers, supervisors and staff to enable them to carry out their duties and
responsibilities relating to retention and disposal of medical records.

11. Compliance

The Freedom Information Act came into force in January 2000 and non-
compliance will mean that the Trust is in breach of this legislation. The
consequences for the Trust include, fines, litigation, and adverse publicity.

This Policy and Procedure will ensure that the Trust is compliant with the
Freedom of Information Act, particularly Section 46 and the Code of Conduct on
Records Management.

12. Launch Plan

The launch plan for the Retention and Disposal of Records Policy and Procedure

• Ratification by Medical Records Committee

• Information Governance Committee
• E Communication to all Trust staff.
• Addition to Trust intranet.
• Article in Heartbeat.

13. Review

This Policy and Procedure will be reviewed every 3 years by the Information
Governance Manager and the Head of Medical Records.

The effectiveness of retention and disposal will be evaluated by use of the

following tools:

• The FOI Procedure.

• Information Governance Toolkit.
• Healthcare Commission.
• NHSLA Risk Management Standards

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_______________________End of Policy and Procedure_______________

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Retention and Disposal of Corporate Records (Schedule) – Attachment 1

ESTATES
Approved Suppliers 11 Consumer Protection
Lists Act 1987

Building and Permanent

engineering works,
inclusive of major
projects abandoned or
deferred - key records,
(e.g. Final accounts,
surveys, site plans, bills
of quantities)
Building and These documents must The general principle to
engineering works, be considered for be followed in regard to
inclusive of major permanent preservation these records is that
projects abandoned or but advice on they should be
deferred - town and appropriate place of preserved for the life of
country planning deposit is to be obtained the buildings and
matters and all formal before any final decision installations to which
contract documents is made they refer.
(e.g. Executed
agreements, conditions
of contract,
specifications, “as built”
record drawings and
documents on the
appointment and
conditions of
engagement of private
buildings and
engineering consultants.
Buildings - papers 3 After occupation
relating to occupation ceases.
(but not Health 7 Safety Construction Design
information) Management
Regulations 1994
Contracts - Non sealed 6 The Limitation Act 1980
(Property) on
termination
Contracts - Non sealed 6 The Limitation Act 1980
(other) on termination

Contracts - sealed Contracts under seal These documents must

and associated records be considered for
should be kept for a permanent preservation

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minimum of 15 years but advice on
appropriate place of
deposit is to be obtained
before any final decision
is made
Deeds of Title Permanent

Drawings The general principle to These documents must

be followed in regard to be considered for
these records is that permanent preservation
they should be but advice on
preserved for the life of appropriate place of
the buildings and deposit is to be obtained
installations to which before any final decision
they refer. is made
Engineering works Permanent

Equipment 11 Consumer Protection

Act 1987
Inspection Reports - e.g. Lifetime Normally retain for the
Boilers, lifts etc. lifetime of an
installation. However, it
is necessary to assess
whether obligations
incurred during the
lifetime may not be
invoked until afterwards,
in which case a
judgement must be
made. If there is any
measurable risk of a
liability in respect of
installations beyond
their operational lives,
records of this kind
should be retained
indefinitely.

Inventories (not in 1.5

current use) of items
having a life of less than
5 years

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Land Surveys/Registers These documents must be considered for
permanent preservation but advice on appropriate
place of deposit is to be obtained before any final
decision is made

Manuals Lifetime

Manuals - policy and These documents must be considered for

procedure permanent preservation but advice on appropriate
place of deposit is to be obtained before any final
decision is made

Maps These documents must be considered for

permanent preservation but advice on appropriate
place of deposit is to be obtained before any final
decision is made
Mortgage documents Permanent
(acquisition, transfer
and disposal)

Plans - Building (As These documents must be considered for

Built) permanent preservation but advice on appropriate
place of deposit is to be obtained before any final
decision is made

Plans - Buildings Lifetime See Inspection reports

(Detailed)

Plans - Engineering Lifetime See Inspection reports

Products - Liability 11 Consumer Protection

Act 1987
Project Files (under 6
£100,000) on
termination - including
abandoned or deferred
projects
Project Team Files - 3
summary retained

Property Acquisitions Permanent

Dossiers

Property Disposal Permanent

Dossiers

Site Files As per Contracts

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Structure Plans (LA’s) These documents must be considered for

permanent preservation but advice on appropriate
place of deposit is to be obtained before any final
decision is made
Surveys - building and These documents must be considered for
engineering permanent preservation but advice on appropriate
place of deposit is to be obtained before any final
decision is made.

FINANCIAL

Accounts – Annual Permanent

(Final – one set only)

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Accounts - cost 3
Accounts – working 3
papers
Accounts – minor 2 From completion of
records (cheques, petty audit
cash, travel &
subsistence accounts)
Advance letters 6
Approved suppliers list 11 Consumer Protection
Act 1987
Audit Records – original 2 From completion of the
records audit
Audit Reports (including 2 After formal clearance
management letters, by the Statutory Auditor
final accounts)
Bank Statements 2 From completion of the
audits
Bills, receipts and 6
cleared cheques
Budgets 2 From completion of the
audit
Buildings and Permanent
engineering works,
inclusive of major
projects abandoned or
deferred – key records
Buildings and See opposite For the life of the
engineering works, buildings and
inclusive of major installations to which
projects abandoned or they refer
deferred - town and
country planning
matters and all formal
contract documents
(e.g. Executed
agreements, conditions
of contract,
specifications, "as built"
record drawings and
documents on the
appointment and
conditions of
engagement of private
buildings and
engineering consultants.
* The general principle
to be followed in regard
to these records is that

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they should be
preserved for the life of
the buildings and
installations to which
they refer.

Buildings – papers 3 After occupation ceases

relating to occupation (Construction Design
(not H&S) Management
Regulations 1994)
Capital Charges Data 2 From completion of the
audit
Cash Books 6 The Limitation Act 1980
Cash Sheets 6 The Limitation Act 1980

Contracts – non sealed 6 The Limitation Act 1980

(property) on
termination
Contracts – non sealed 6 The Limitation Act 1980
(other) on termination
Contracts - sealed 15
Creditor payments 3
Day files .5 (6 months)
Debtors records – 2 From completion of the
cleared audit
Debtors records – 6
uncleared
Deeds of title Permanent
Expense claims 2 From completion of
audit
Forms – 10 Originals are sent to
Superannuation Pensions Agency
SD55(ADP) and SD55J
(copies)
Income and expenditure 6
journal
Invoices 6 The Limitation Act 1980
Ledgers 6 The Limitation Act 1980
Mortgage documents Permanent

Nominal rolls 6 (max) Normally only current

and the immediately
preceding roll to be kept
Pay Roll – full-time 6
medical staff

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Pay Roll – other staff 6
Receipts 6 The Limitation Act 1980
Superannuation 10
Accounts
Superannuation 10
Registers
Tax forms 6
VAT records 6 Unless shorter period
agreed with Customs &
Excise
Wages/Salary records 10

EMPLOYEE

CVs for non-executive 5 Following term of office

directors (successful)
CVs for non-executive 2
directors (unsuccessful
applicants)
Day files .5 (6 months)
Diaries – office – on 1
completion
Establishment records 6 After subject leaves
(personal files, contracts service or until his/her
references & related 70th birthday –
correspondence) whichever is later.

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Only a summary needs
to be kept to age 70
Establishment records 2
(attendance, annual
leave, timesheets etc.)
Job Advertisements 1
Job Applications 3
(following termination of
employment)
Job descriptions 3
(following termination of
employment)
Leavers dossiers 6
(provided summary
retained)
Nurses training records 30
Study leave applications 1.5

SUPPLIES

Contracts – non sealed 6 The Limitation Act 1980

(property) on
termination
Contracts – non sealed 6 The Limitation Act 1980
(other) on termination
Contracts - sealed 15
Day files 0.5 (6 months)
Deeds of title Permanent
Delivery notes 1.5
Products - liability 11 Consumer Protection
Act 1987
Requisitions 1.5
Stock control reports 1.5
Stores records – major 6
(stores ledgers etc.)

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Stores records – minor 1.5
(requisitions, issue
notes, good received
books etc.)
Supplies records – 1.5
minor ( routine papers
etc.)
Tenders (unsuccessful) 6 The Limitation Act 1980

Tenders (Successful) See Contracts

ADMINISTRATION

Litigation Dossiers 10 Where legal action has

(complaints including been commenced, keep
accident reports) as advised by legal
representatives
Meeting papers – Permanent
committees, sub-
committees (master
copies)
Minutes of the NHS Permanent
Trust or Health Authority
major committees and
sub-committees - signed
Minutes – reference 1
copies
Press cuttings 1
Receipt for registered 1.5
and recorded delivery
mail
Record of custody and 1.5

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transfer of keys
Software licenses Lifetime
Trust Administered by Permanent
SHAs –
Trust documents without 6
permanent relevance

Clinical Records

The retention periods, which are listed below, reflect minimum requirements
of clinical need. Personal health records may be required as evidence in legal
actions; the minimum retention periods take account of this requirement. It is
not necessary to keep every piece of paper received in connection with
patients. NHS Trusts and Health Authorities should determine, in consultation
with their health professionals, which elements should be considered as a
permanent part of the record, and which should be transient and discarded as
their value ceases.

Before any destruction takes place, ensure that

(a) there is consultation with the relevant health professional body or records
committee and actions clearly minuted;
(b) any other local clinical need is considered;
(c) the value of the records for long-term research purposes has been
assessed, in consultation with an appropriate place of deposit.

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-pre-1948 records. Should by now have been transferred
for permanent preservation or
destroyed. Any pre-1948 records
which still exist should be considered
for permanent preservation,
undergoing an appraisal procedure as
described in the box above.
-Children and young people Until the patient's 25th birthday, or
26th if young person was 17 at
conclusion of treatment; or 8 years
after patient's death if death occurred
before 18th birthday.

Abortion- Certificate A 3 Abortion Regulations

(Form HSA1) and 1991, Statutory
Certificate B Instrument No. 499
(Emergency Abortion)
Accident & Emergency 2 years on site & then to Local decisions should
Registers long term storage being be made with regard to
marked appropriately the permanent
that in 60 years to be preservation of theses
sent to Archivist. records, in consultation
with relevant health
professionals and
places of deposit.

Admission books 2 years on site & then to Local decisions should

long term storage being be made with regard to
marked appropriately the permanent
that in 60 years to be preservation of theses
sent to Archivist records, in consultation
with relevant health
professionals and
places of deposit.
Birth registers (i.e. 2 years on site & then to Local decisions should
register of births kept by long term storage being be made with regard to
the hospital) marked appropriately the permanent
that in 60 years to be preservation of theses
sent to Archivist records, in consultation
with relevant health
professionals and
places of deposit.

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Death registers (i.e. Local decisions should be made with regard to the
register of deaths kept permanent preservation of theses records, in
by the hospital) consultation with relevant health professionals and
places of deposit.

Clinical Diaries To be agreed with

Clinical groups in line
with their Professional
Guidance and Trust
Guidance.
Donor records 11 years post transplantation. Committee on
Microbiological Safety of Blood and Tissues for
Transplantation (MSBT); guidance issued in 1996.
Clinical Records 4 years after conclusion of treatment or 8 years
General (not covered after death.
above)
Laboratory records Local decisions should be made with regard to the
permanent preservation of theses records, in
consultation with relevant health professionals and
places of deposit.
Maternity (all obstetric 25 years Refer to Circular
and midwifery records HSG(94)11 for
including those of additional guidance on
episodes of maternity retention and storage of
care that end in stillbirth maternity records.
or where the child later
dies)
Mentally disordered 20 years after no further treatment considered
persons records (within necessary; or 8 years after the patient’s death if
the meaning of the patient died while still receiving treatment.
Mental Health Act 1983)
Occupational Health 40 years

Oncology 8 years after conclusion of treatment especially

when surgery only involved.
Consideration may wish to be given to BFCO(96)3
issued by the Royal College of Radiologists which
recommends permanent retention on a computer
database when patients have been given
chemotherapy and radiotherapy.
Operating Theatre 2 years on site & then to Local decisions should
registers long term storage being be made with regard to
marked appropriately the permanent
that in 60 years to be preservation of theses
sent to Archivist. records, in consultation
with relevant health
professionals and

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places of deposit.
Patient Activity Data 3

Patient involved in 15 years after conclusion of treatment. EEC Note

clinical trials for Guidance: Good Clinical Practice for Trials on
Medicinal Products in the European Community,
section 3.17 (see- Pharmacology & Toxicology
1990,67,361-372.)

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MEDICAL RECORD RETENTION AND DESTRUCTION POLICY

Each record must be examined prior to destruction and the retention periods
below applied.

This policy applies to the main medical record folder and all locally held medical
records, manual and electronic

Retention periods must be calculated from the end of the calendar year and
from the date of the patient's last attendance to the Trust.

LIVE PATIENT RECORDS

Record Type Retain for

Obstetric 25 years from date of last obstetric attendance

Oncology/Chemotherapy/Radiotherapy 8 years from date of last Onc/Chemo/Radio

attendance
Haematology 4 years from date of last Haem attendance, then
forward to Haematology Data Manager for local
retention
Cystic Fibrosis 4 years after conclusion of treatment – then forward
to Dr Whitehouse’s Sec for local retention
Patients known to be involved in Clinical Drug 15 years after conclusion of treatment. NB Clinical
trials Drug trial documentation should not be stored within
the patient’s NHS medical record
Children and young people Until the patient’s 25th birthday, or 26th birthday if the
young person was aged 17 yrs at conclusion of
treatment.
Pre 1948 records Permanently - refer to Library Manager

Donor records 11 years post transplantation

All other general health records not covered 4 years after conclusion of treatment
above
Where rear cover of record is signed by Permanently
consultant

DECEASED PATIENT RECORDS

Deceased records not covered below 4 years from date of death

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Haematology 4 years then forward to Haematology Data Manager
for local retention
Cystic Fibrosis 8 years - then forward to Dr Whitehouse’s Secretary
for retention
Oncology 8 years from date of death

Stillbirth 25 years

dren & Children & Young people under 18 yrs 8 years from date of death
.stillbirths)

Obstetric records 8 years from date of death

Where rear cover of record is signed by 4 years from date of death - then forward to
consultant appropriate consultant for retention

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