Additional services records in community pharmacy

Unique record

Yes, this is likely to be the only record.

Reason for keeping

This is a legal requirement.

Minimum period

Retain for 12 months.

Comment

Records can be kept electronically or in hard copy.

Provenance

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013: Keep records for at least 12 months or such longer period as the commissioner may reasonably require (Direction 12(5)(e)).

Unique record

Yes, this is likely to be the only record.

Reason for keeping

This is a legal requirement.

Minimum period

Retain for:

• 8 years for adults aged 18 years and over
• 2 years for consent forms for post payment verification

Comment

Records can be kept electronically or in hard copy.

Provenance

• The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013 consolidated directions and subsequent amendments.
• Community Pharmacy Seasonal Influenza Vaccine Service: All relevant paperwork must be managed in line with RMCoP.
• Pharmacy Influenza Vaccination PGD: Keep records for audit purposes and post payment verification.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

This is a legal requirement.

Minimum period

Retain for 2 years.

Comment

Records can be kept electronically or in hard copy.

Provenance

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013: Keep records for at least two years after the date on which the consultation to which the record relates is carried out (Direction 5(1)(l)).

Unique record

Yes, this is likely to be the only record.

Reason for keeping

This is a legal requirement.

Minimum period

Retain for 2 years.

Comment

Records can be kept electronically or in hard copy.

Provenance

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013: Keep records for at least two years after the date on which the service intervention is completed or discontinued (Direction 7(1)(n)).

Unique record

Yes, this is likely to be the only record.

Reason for keeping

To demonstrate compliance with the interim best practice recommendation.

Minimum period

Retain for 2 years.

Comment

Records can be kept electronically or in hard copy.

Provenance

All relevant records must be managed in line with RMCoP.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

This is a legal requirement.

Minimum period

Retain for 12 months.

Comment

Records can be kept electronically or in hard copy.

Provenance

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013: Keep records for at least 12 months or such longer period as the commissioner may reasonably require (Direction 10(2)(d)).

Unique record

Yes, this is likely to be the only record.

Reason for keeping

This is a legal requirement.

Minimum period

For adults aged 18 years and over:

• retain for 8 years

For a child:

• retain until the 25th birthday or 26th birthday if the patient was 17 years when treatment finished

Provenance

All relevant records must be managed in line with RMCoP.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for audit purposes.

Minimum period

Retain for 6 complete tax years.

Comment

This applies to all payment claims, invoices and patient consent forms relating to any advanced or enhanced service.

Enhanced service consent forms represent consent at the point in time the service is provided and are not proof of ongoing consent.

Provenance

VAT regulations 2005 for invoices. Individual signed consent forms support the invoiced claim.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for reference.

Minimum period

The individual’s clinical record is maintained for 8 years for an adult and up to the 26th birthday if given to a child under the age of 18, therefore records should be retained to cover this period.

Comment

This relates to medicines administered under Patient Specific Direction (PSD), Patient Group Direction (PGD) or National Protocol.

Provenance

Retaining legal mechanism documentation (SPS page)

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for audit purposes.

Minimum period

Retain for 2 years.

Provenance

This is recommended best practice.

Unique record

Yes, unless the results are forwarded to the patient’s GP.

Reason for keeping

Keep for audit purposes.

Minimum period

Retain for 2 years.

Provenance

This is a best practice recommendation.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for audit purposes.

Minimum period

For adults aged 18 yrs and over:

• retain for 8 years
• retain for 10 years in cases of implant or device insertion

For a child:

• retain until the 25th birthday or 26th birthday if the patient was 17 years when treatment finished
• in cases of implant or device insertion, keep the record as above or for 10 years, whichever is longer

Comment

Note that the longest licence period for a contraceptive device is 10 years.

Where individual patient records are kept by a sexual health team, a shorter minimum period for retaining records (for the purpose of reference) may be stated in the service level agreement.

Provenance

• all relevant records must be managed in line with RMCoP
• Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists. Service standards for record keeping, July 2019

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for audit purposes.

Minimum period

Retain for 2 years.

Provenance

All relevant records must be managed in line with RMCoP.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for audit purposes.

Minimum period

Retain for 2 years.

Comment

This relates to supply of e.g. NRT not via FP10 or via PGD.

Provenance

All relevant records must be managed in line with RMCoP.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for reference.

Minimum period

Retain for 2 years.

Provenance

This is a best practice recommendation.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for reference.

Minimum period

Retain for as long as the assessment remains valid, plus 1 year

Comment

This relates to records of assessment and outcomes of patients’ needs in respect of medicines. Assessment should be repeated if patient circumstances change.

Provenance

This is a best practice recommendation.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for reference

Minimum period

Retain for 6 years after the last use.

Provenance

All relevant records must be managed in line with RMCoP.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for reference.

Minimum period

Retain for 2 years.

Comment

This relates to evidence of participation in local public health campaigns.

Provenance

Where requested by the commissioner to do so, records should be kept to demonstrate compliance with Terms of service of NHS Pharmacists (Schedule 4, part 2, paragraph 18(b)) to regulation 11(1)(a)(i) of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013.

Unique record

Yes, this is likely to be the only record.

Reason for keeping

Keep for audit purposes.

Minimum period

Retain for 2 years.

Comment

This recommendation applies to any other paper records pertaining to individual patient care in community pharmacy not covered elsewhere in this resource.

It is accepted that, where appropriate, records relating to patient care (e.g. self-care, signposting, telephone queries) should be entered on the PMR, either directly or transferred from paper records. Entries made on the PMR should be kept permanently.

Provenance

• This is a best practice recommendation.
• Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet (GPhC) contains further information.