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Miscellaneous records in hospital pharmacy

Published Last updated See all updates
Topics: Record keeping

Requirements for paperwork relating to signatures, self-administration, superseded IV monographs, formulary committee, PSD, PGD and national protocols.

Contents

  1. Miscellaneous records
  2. Specific types of records
    1. Healthcare professionals' signatures
    2. Formulary committee meetings
    3. Medicines administered under PSD, PGD or National Protocol
    4. Self-administration records
    5. Superseded injectable medicine administration monographs
  4. Other record keeping resources
  5. All record keeping resources
  6. Update history

Miscellaneous records

Everyone within a health and care organisation is responsible for managing records appropriately. It is therefore important that you understand how records relating to other pharmacy activities should be managed within the pharmacy.

Specific types of records

Unique record

Where paper-based systems remain in use, this is likely to be the only record.

Reason for keeping

This is a best practice standard where paper-based systems are in use, when a list should also be kept for reference. Where digital systems are in use, control of passwords and digital access achieves the same objectives. A list may then be considered superfluous.

The requirements for signatures on orders and prescriptions for Controlled Drugs are listed in Misuse of Drugs Regulations 2001, regulations 14, 15, and 16 https://www.legislation.gov.uk/uksi/2001/3998/regulation/14

Minimum period

Retain for the duration of an employee’s contract.

Comment

Destroy 1 year after termination of employment.

Provenance

GDPR Principle (e): Storage limitation [20]: Do not keep personal data for longer than required.

Unique record

No, there is likely to be more than one copy.

Reason for keeping

Keep for reference.

Minimum period

Retain for 20 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

This is a legal requirement.

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. For implants in an adult, records must be kept for 10 years.

Provenance

Retaining legal mechanism documentation (SPS page).

Unique record

No, there is likely to be more than one copy.

Reason for keeping

Keep for reference.

Minimum period

Retain for 8 years.

Comment

Keep the record in the patient’s medical notes after discharge.

Provenance

  • This is a best practice recommendation.
  • All relevant records must be managed in line with RMCoP.

Unique record

No, there is likely to be more than one copy.

Reason for keeping

Keep for reference.

Minimum period

Retain for 10 years.

Comment

May provide useful background information for dealing with complaints regarding injectable administration of medicines.

Provenance

This is a best practice recommendation.

Other record keeping resources

All record keeping resources

Record keeping

Advice and guidance to support appropriate retention and storage of pharmacy-related records.

Update history

  1. Commentary on HCP signatures amended & expanded
  1. Link updated for the Records Management Code of Practice (RMCoP).
  1. Republished
  1. Published